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Abstract Objective: To describe Top-hat results and their association with margin status and disease relapse in a referral facility in Brazil. Methods: 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. Results: 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. Conclusion: 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.

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Early stages of cervical cancer in young women need conservative treatments. Electrosurgical therapies (LLETZ, LEEP, SWETZ, NETZ) have been recommended for these women. However, there are recommendations to perform a second excision when the specimen margins are not free of disease. This can lead to some important complications. This article aims to verify the frequency of residual invasive or microinvasive disease after the excisional procedure in women with IA1CC. Data on women with IA1CC diagnosed between 1990 and 2022, were retrieved from medical records. Post-treatment disease was detected during a second surgical procedure or postoperative follow-up. Among the 69 included women, three (4.3 percent; CI95 percent 0-9.2) had residual microinvasive lesions, while none showed invasive disease during a second procedure or follow-up. Only the age of 37 years or more was significantly related to the presence of preinvasive or microinvasive residual lesions. Nearly 80 percent of the women who underwent a second procedure showed no residual lesions. The absence of invasive disease in a second procedure or during the follow-up of these women and the large proportion of women with no residual lesion questions the need for a new surgical procedure even when the surgical margins of the initial specimen are involved.

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Objetivo: La biopsia guiada por colposcopia (BGC) marca el manejo de la neoplasia intraepitelial cervical. El objetivo de este estudio fue evaluar la concordancia de los resultados entre la BGC y la escisión amplia de la zona de transformación (LLETZ, large loop excision of the transformation zone), y la utilidad del genotipado del virus del papiloma humano (VPH) para seleccionar a las pacientes con riesgo de lesión intraepitelial escamosa de alto grado/neoplasia intraepitelial cervical 3 (HSIL/CIN3). Método: Se compararon los resultados de la BGC y de la LLETZ, siendo esta última el método de referencia. Se evaluó la relación del genotipo del VPH con el diagnóstico final de HSIL/CIN3. Resultados: La precisión de la biopsia comparada con LLETZ fue del 61,4%. La tasa de concordancia fue del 64,4% para CIN1, del 31,4% para CIN2 y del 77,4% para CIN3. La tasa global de sobrediagnóstico fue del 18,68% y la de subdiagnóstico del 19,89%. En mujeres menores de 30 años, la concordancia fue del 62,79% (CIN1 65%, CIN2 39,58% y CIN3 73,08%), la tasa de sobrediagnóstico del 22,67% y la tasa de subdiagnóstico del 15,11%. La infección por VPH16 tuvo una odds ratio de 3,86 para el diagnóstico final de HSIL/CIN3+. Conclusiones: El diagnóstico de CIN2 por BGC parece insuficiente para seleccionar a las pacientes para tratamiento escisional, principalmente en mujeres jóvenes. El hallazgo de VPH16 es un factor de riesgo de HSIL/CIN3+ independientemente del resultado de la biopsia.

Objective: Colposcopy-guided biopsy (CGB) is a basic tool for the management of cervical intraepithelial neoplasia. The aim of this study is to evaluate the concordance of results between CGB and large loop excision of the transformation zone (LLETZ), and the usefulness of human papillomavirus (HPV) genotyping to select patients at risk of H-SIL/CIN3. Method: The results of colposcopy-guided biopsy and LLETZ were compared, with LLETZ being the gold standard. The relationship of HPV genotype to the final diagnosis of CIN3 was assessed. Results: The accuracy of CGB compared to LLETZ was 61.4%. The concordance rate was 64.4% for CIN1, 31.4% for CIN2 and 77.4% for CIN3. The overall overdiagnosis rate was 18.68% and underdiagnosis rate was 19.89%. In women under 30 years of age the concordance rate was 62.79% (CIN1 65%, CIN2 39.58% and CIN3 73.08%), and the rate of overdiagnosis and underdiagnosis was 22.67% and 15.11%, respectively. HPV16 infection had an odds ratio of 3.86 for the final diagnosis of CIN3+ and the result was significant regardless of the biopsy result. Conclusions: The CGB result as CIN2 is inaccurate and seems insufficient to select patients for excisional treatment, mainly in young women. HPV16 infection is a risk factor for CIN3+ regardless of the colposcopy-guided biopsy result.

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OBJECTIVE: To detect factors related to overtreatment with the "Screen-and-treat" approach (S&T) in women with suspicious cervical precancerous lesions. STUDY DESIGN: 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 %). RESULTS: 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). CONCLUSIONS: 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.

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Abstract Purpose: To evaluate recurrence rates and risk factors among women with stage IA1 cervical cancer without lymph vascular space invasion managed conservatively. Methods: retrospective review of women with stage IA1 squamous cervical cancer who underwent cold knife cone or loop electrosurgical excision procedure, between 1994 and 2015, at a gynecologic oncology center in Southern Brazil. Age at diagnosis, pre-conization findings, conization method, margin status, residual disease, recurrence and survival rates were collected and analyzed. Results: 26 women diagnosed with stage IA1 squamous cervical cancer without lymphovascular space invasion underwent conservative management and had at least 12 months follow-up. The mean follow-up was 44.6 months. The mean age at diagnosis was 40.9 years. Median first intercourse occurred at age 16 years, 11.5% were nulliparous and 30.8% were current or past tobacco smokers. There was one Human immunodeficiency virus positive patient diagnosed with cervical intraepithelial neoplasia grade 2 at 30 months after surgery. However, there were no patients diagnosed with recurrent invasive cervical cancer and there were no deaths due to cervical cancer or other causes in the cohort. Conclusion: Excellent outcomes were noted in women with stage IA1 cervical cancer without lymphovascular space invasion and with negative margins who were managed conservatively, even in a developing country.

Resumo Objetivo: Avaliar recidiva e seus fatores de risco em mulheres com câncer do colo do útero estádio IA1 sem invasão do espaço linfovascular tratadas conservadoramente. Métodos: Estudo de coorte retrospectivo de pacientes com câncer do colo do útero IA1 escamoso submetidas a cone do colo do útero, entre 1994 e 2015, em um centro de ginecologia oncológica do sul do Brasil. Foram revisados e analisados idade no diagnóstico, achados pré-conização, método de conização, margens, doença residual, recorrência e sobrevida. Resultados: 26 mulheres diagnosticadas com câncer do colo do útero estádio escamoso sem invasão do espaço linfovascular foram submetidas a tratamento conservador, com seguimento mínimo de 12 meses. O tempo médio de seguimento foi 44,6 meses. A média de idade no diagnóstico foi 40,9 anos. A primeira relação sexual ocorreu aos 16 anos (mediana), 11,5% eram nulíparas e 30,8% eram tabagistas atuais ou passadas. Houve um caso de recidiva de neoplasia intraepitelial cervical grau 2 aos 30 meses em uma paciente com vírus da imunodeficiência humana. Não houve pacientes diagnosticados com câncer de colo do útero invasor recorrente, e não houve mortes por câncer do colo do útero ou outras causas. Conclusão: Os resultados observados após tratamento conservador em mulheres com câncer cervical escamoso IA1 sem invasão do espaço linfovascular com margens negativas foram excelentes, mesmo em um país em desenvolvimento.

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Abstract Objective To evaluate whether colposcopy-directed biopsy is necessary to increase the accuracy of diagnosing cervical intraepithelial lesions in relation to colposcopy. Methods We performed a retrospective, observational study by analyzing medical records obtained fromHospital de Clínicas do Paraná fromFebruary 2008 to February 2018. Patients with results of Pap tests, colposcopy, colposcopy-directed biopsy, and surgical procedures (high-frequency surgery or cold conization) were included. Data such as quadrants involved during colposcopy and age differences were also analyzed. Results A total of 299 women were included. Colposcopy was found to have an accuracy rate of 76.25% (95% confidence interval [CI], 71.4-81.1). Among the highest-grade lesions, the accuracy rate was 80.5% (95% CI, 75.7-85.3). The accuracy rates for biopsy were 79.6% (95% CI, 75-84.2) and 84.6% (95% CI, 80-89.1) for the highest-grade lesions. High-grade lesions were accurately confirmed in 76.9% and 85% of patients with 1 and 2 or more affected quadrants, respectively. For women younger than 40 years, the accuracy rates were 77.6% and 80.8% for colposcopy and biopsy, respectively. For women 40 years or older, the accuracy rates were 72.5% and 76.3% for colposcopy and biopsy, respectively. Conclusion There is no difference between the accuracy of colposcopy and that of biopsy in diagnosing cervical intraepithelial lesions in relation with the result of conization. The patients who received the greatest benefit when biopsy was not performed were those with high-grade lesions at colposcopy, a lesion involving 2 or more quadrants, and those younger than 40 years.

Resumo Objetivo Avaliar se a biópsia colpodirigida é necessária para aumentar a acurácia diagnóstica nas lesões intraepiteliais de colo uterino em relaçãoà colposcopia. Métodos Estudo retrospectivo, observacional, incluindo pacientes submetidas a colposcopia, biópsia colpodirigida, e procedimento cirúrgico (cirurgia de alta frequência ou conização a frio), no período de fevereiro de 2008 a fevereiro de 2018, no Hospital de Clínicas da Universidade Federal do Paraná. Dados como número de quadrantes da lesão presentes na colposcopia, número de fragmentos retirados nas biópsias e diferenças por idade também foram analisados. Resultados Um total de 299 mulheres foram incluídas. Foi encontrada uma acurácia de 76,25% (intervalo de confiança [IC] 95% 71,4-81,1) entre a colposcopia e a conização, sendo 80,5% % (IC 95% 75.7-85.3) nas lesões de maior grau. A acurácia da biópsia foi de 79,6% (IC 95% 75-84,2), sendo 84,6% (IC 95% 80-89,1) nas lesões de maior grau. Pacientes com 1 quadrante acometido tiveram confirmação de 76,9% nas lesões de maior grau, enquanto as com 2 quadrantes acometidos apresentaram o mesmo resultado em 85% dos casos. A acurácia com a biópsia de 1 fragmento foi de 78% e com2 ou mais fragmentos 80%. Paramulheres com menos de 40 anos, a acurácia foi de 77,6% e 80,8% para colposcopia e biópsia, respectivamente. Para mulheres com 40 anos ou mais, a acurácia foi de 72,5% e 76,3% para colposcopia e biópsia, respectivamente. Conclusão Não há diferença entre a acurácia da colposcopia e a da biópsia colpodirigida no diagnóstico de lesões intraepiteliais cervicais em relação ao resultado da conização. As pacientes que tiveram o maior benefício quando a biópsia não foi realizada foram as que apresentaram lesão de alto grau na colposcopia e aquelas com menos de 40 anos, não existindo benefício emrealizar biópsia previamente a conização neste grupo de pacientes.

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PURPOSE: To describe the results of 610 patients who underwent LEEP and evaluate factors related to a negative margin. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

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As neoplasias intraepiteliais cervicais correspondem a alterações identificadas por rastreamento citológico cervical e estudo histológico, pós-biópsia incisional guiada por colposcopia ou procedimento diagnóstico excisional. Podem ser tratadas com abordagens conservadoras e procedimentos excisionais. A vacinação anti-HPV e o tratamento excisional oportuno constituem, respectivamente, prevenção primária e secundária contra o câncer do colo uterino.(AU)

Cervical intraephitelial neoplasms correspond to changes identified by cervical citological screening and histological study, post-incisional biopsy guided by colposcopy or excisional diagnostic procedure. They can be treated with conservative approaches and excision procedures. Anti-HPV vaccination and timely excional treatment are primary and secondary prevention against cervical cancer, respectively.(AU)

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As células glandulares atípicas representam 0,2% a 2,1% dos resultados dos testes de Papanicolaou. Mesmo com essa baixa prevalência, tem um significado importante no diagnóstico do câncer cervical e endometrial, tendo em vista que tais células e subcategorias, associadas à idade da paciente, podem prenunciar um número expressivo de doença intraepitelial, doença invasiva do endocérvix, endométrio e até neoplasias anexiais. E não se pode esquecer do importante número de resultados histológicos benignos, identificados no seguimento dessas pacientes, muitas vezes assintomáticas.(AU)

Atypical glandular cells represent 0,2% to 2,1% of Pap test results even with this low prevalence has an important significance in the diagnosis of cervical and endometrial cancer, considering that such cells and subcategories associated with the patient's age can predict a significant number of intraepithelial disease, invasive disease of the endometrium, endocervix and even adnexial neoplasms; no forgetting the important number of benign histological results, identified in the follow up of these patients, often asymptomatic.(AU)

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Abstract Objective To observe if the histopathological result of a conization performed after cervical adenocarcinoma in situ diagnosis is compatible with the histopathological analysis of a subsequent hysterectomy. Methods The present descriptive and observational research consisted of the analysis of the medical records of 42 patients who were diagnosed with in situ adenocarcinoma postconization. The analysis consisted of whether there was compatibility between the histopathological reports of conization and hysterectomy and if there was an association between adenocarcinoma in situ and another neoplasia (squamous disease). Interpretation of any immunohistochemistry reports obtained was also performed. In addition, clinical and epidemiological data were also analyzed. Results A total of 42 conizations were performed, 33 (79%) were cold knife conizations and 9 (21%) were loop electrosurgical excision procedures (LEEPs). Of the patients analyzed, 5 (10%) chose not to undergo subsequent hysterectomy to preserve fertility or were < 25 years old. Out of the 37 patients with adenocarcinoma in situ who underwent subsequent hysterectomy, 6 (16%) presented with residual disease. This findingprovedincompatiblewiththe finding of the conizations, which had ruled out invasive cancer. Conclusion The prevalence of adenocarcinoma in situ increased in the past years. There is still a large part of the medical literature that advocates the use of conservative treatment for this disease, even though it is common knowledge that it is a multifocal disease. However, the majority of studies advocate that hysterectomy should remain the preferred treatment for women who have already completed their reproductive purpose.

Resumo Objetivo Observar se o resultado proveniente de uma conização realizada após o diagnóstico de adenocarcinoma cervical in situ é compatível com a análise histopatológica da histerectomia. Métodos A pesquisa foi descritiva e observacional e consistiu na análise de prontuário de 42 pacientes que tiveram o diagnóstico de adenocarcinoma in situ obtidas por conização. Foram analisados se havia compatibilidade entre os laudos de conização e histerectomia, margens do cone, se havia associação com outra patologia (doença escamosa) e interpretação de eventuais laudos histoquímicos obtidos. Além disso, também foram analisados dados clínico-epidemiológicos. Resultados Foram realizadas 42 conizações, sendo 33 (79%) por cone clássico e 9 (21%) por cirurgia de alta frequência. Das pacientes analisadas, 5 (10%) não foram submetidas a histerectomia por desejarem manter a fertilidade ou por terem idade < 25 anos. Das 37 pacientes com adenocarcinoma in situ no exame prévio realizado e que foram submetidas à histerectomia posteriormente, 6 (16%) apresentaram doença residual após o procedimento cirúrgico, apresentando laudos do anatomopatológico pós-histerectomia incompatíveis com o achado na conização que atestava margens livres. Conclusão A prevalência do adenocarcinoma in situ vemaumentando cada vez mais. Ainda há uma grande parte da literatura que defende o uso do tratamento conservador para esta doença, mesmo sabendo que ela é uma doença multifocal e que pode estar presente mesmo em situações nas quais o anatomopatológico evidencie margens livres. Tendo em vista essas características, a maioria preconiza que a histerectomia continua a ser o tratamento preferencial nas mulheres que já completaram o seu intuito reprodutivo.

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O adenocarcinoma cervical in situ é uma doença rara, totalmente curável, diagnosticada predominantemente por meio de rastreamento cervicouterino seguido de biópsia guiada por colposcopia e/ou conização. O tratamento em pacientes que desejam preservar a fertilidade pode ser realizado num contexto ambulatorial; aquelas com paridade definida deverão ser abordadas em nível terciário.(AU)

Cervical adenocarcinoma in situ is a rare, fully curable disease diagnosed predominantly through cervical-uterine screening followed by colposcopy-guided biopsy and/or conization. Treatment in patients wishing to preserve fertility may be performed in an outpatient setting; those with defined parity should be approached at the tertiary level.(AU)

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Resumen ANTECEDENTES: Existen múltiples opciones para practicar una histerectomía: por vía vaginal, abdominal laparotómica, laparoscópica o robótica. En pacientes que van a intervenirse por enfermedad benigna puede hacerse mediante la extirpación del cuerpo uterino (histerectomía parcial o supracervical). La preocupación por la posible aparición de una lesión neoplásica en el muñón cervical remanente ha dado lugar a investigaciones acerca de las ventajas de la exéresis del cuello uterino (histerectomía total). CASO CLÍNICO: Paciente de 36 años, intervenida para histerectomía supracervical con salpingectomía bilateral laparoscópica, por útero miomatoso sintomático. Posterior a la cirugía apareció una lesión preneoplásica de alto grado; se le indicó conización cervical. CONCLUSIÓN: Algunos expertos advierten que los riesgos de extirpar el cuello uterino son lo suficientemente notables como para optar por la técnica parcial en pacientes sin antecedentes de patología cervical, sobre todo si tienen cuadros adherenciales o endometriosis del tabique rectovaginal. Por el contrario, otros grupos indican que ante la baja tasa de complicaciones de la histerectomía total y la posibilidad de una patología neoplásica posterior, no está justificada la preservación cervical.

Abstract BACKGROUND: There are multiple approaches to perform a hysterectomy; the classic vaginal route, the laparotomic abdominal or the newest endoscopic techniques, such as laparoscopic or robotic. In patients undergoing benign pathology, the technique can only be performed by removing the uterine body (subtotal or supracervical hysterectomy). However, the concern about the possible occurrence of a neoplastic lesion in the remaining cervical stump has led to investigations into the benefits of also performing the cervical exeresis (total hysterectomy). Our goal is to present a review on the current situation of the topic, concluding that there is still no scientific consensus on which technique is the most recommended. CLINICAL CASE: 36-year-old woman who underwent supracervical hysterectomy with laparoscopic bilateral salpinguectomy due to symptomatic myomatous uterus. After surgery, he presented a high-grade preneoplastic lesion, which indicated that cervical conization was indicated. CONCLUSION: Some experts argue that the risks of performing the removal of the cervix are notable enough to indicate subtotal technique in patients without a history of cervical pathology, especially if they have adhesion or endometriosis of the rectovaginal septum. On the contrary, other working groups indicate that cervical preservation is not justified due to the low complication rate of the total hysterectomy technique and the possibility of developing a subsequent neoplastic pathology.

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Resumen: OBJETIVO: Determinar la asociación entre los márgenes afectados con la persistencia-recurrencia de neoplasia intraepitelial cervical, persistencia del virus del papiloma humano y las reintervenciones. MATERIALES Y MÉTODOS: Estudio de casos y controles anidado en una cohorte retrospectiva del Complexo Hospitalario Universitario de Ourense (enero 2010-octubre 2017). Criterio de inclusión: mujeres con al menos una revisión postintervención. Criterios de exclusión: mujeres sin evidencia de displasia de alto grado en la pieza de conización y a las que no se dio seguimiento. Variables de estudio: edad, tabaquismo, preservativo, anticonceptivos orales, vacunación contra VPH, persistencia-recurrencia de NIC y de VPH y reintervención. Se realizaron pruebas paramétricas y no paramétricas entre las variables. RESULTADOS: La cohorte se integró con 248 mujeres, de éstas 81 (32.6%) tuvieron afectación de los márgenes quirúrgicos en la conización. La inmunosupresión, el tabaquismo y la anticoncepción oral fueron las asociaciones más frecuentes en los márgenes afectados. El uso de preservativo y la vacunación contra VPH fueron significativamente más frecuentes en los márgenes libres. Los márgenes afectados reportaron mayor persistencia de VPH (50 vs 23.9%; OR 3.17 (1.90-5.26), p < 0.001), enfermedad persistente-recurrente (47.2 vs 22.5%; OR 3.07 (1.84-5.12), p < 0.001) y reintervenciones (40.2 vs 15.4%; OR 3.679 (2.094-6.463), p < 0.028). El margen más afectado fue, en orden descendente, endocervical (55.6%), exocervical (25%) y ambos (19.4%). CONCLUSIONES: El margen afectado confiere un riesgo importante en la evolución de la infección por VPH y la recurrencia de la enfermedad.

Abstract: OBJECTIVE: To determine the association between affected margins with persistence-recurrence of cervical intraepithelial neoplasia, persistence of human papillomavirus and re-interventions. MATERIALS AND METHODS: Study of cases and controls nested in a retrospective cohort of the Complexo Hospitalario Universitario de Ourense (January 2010-October 2017). Inclusion criteria: women with at least one post-intervention check-up. Exclusion criteria: women without evidence of high-grade dysplasia in the conization piece and who were not followed up. Study variables: age, smoking, condom, oral contraceptives, HPV vaccination, persistence-recurrence of CIN and HPV, and re-operation. Parametric and non-parametric tests were performed among the variables. RESULTS: The cohort consisted of 248 women, 81 of whom (32.6%) had affected surgical margins on conization. Immunosuppression, smoking and oral contraception were the most frequent associations in affected margins. Condom use and HPV vaccination were significantly more frequent in free margins. Affected margins reported greater persistence of HPV (50 vs 23.9%; OR 3.17 (1.90-5.26), p < 0.001), persistent-recurrent disease (47.2 vs 22.5%; OR 3.07 (1.84-5.12), p < 0.001), and reinterventions (40.2 vs 15.4%; OR 3.679 (2.094-6.463), p < 0.028). The most affected margin was, in descending order, endocervical (55.6%), exocervical (25%) and both (19.4%). CONCLUSIONS: The affected margin confers a significant risk in the evolution of HPV infection and disease recurrence.

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ABSTRACT OBJECTIVES To determine the efficacy and safety of the use of cryotherapy, cold knife or thermocoagulation compared to Loop Electrosurgical Excision Procedure (LEEP) for the treatment of cervical intraepithelial neoplasia. METHODS Systematic review with meta-analysis of randomized controlled trials in women with cervical intraepithelial neoplasia undergoing treatment with cryotherapy, cold knife, or thermo-coagulation compared with LEEP, to estimate its efficacy and safety. The search was conducted on MEDLINE/PUBMED, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus, until September 2018. RESULTS The total of 72 studies were identified, of which only 8 studies met the inclusion criteria. The treatment of CIN with cold knife decreases the risk of residual disease compared with LEEP (RR, 0.54, 95%CI, 0.30-0.96, p = 0.04). The management of premalignant lesions with cryotherapy, compared with LEEP, increases the risk of disease recurrence by 86% (RR, 1.86, 95%CI, 1.16-2.97, p = 0.01), increases the risk of infections (RR, 1.17, 95%CI, 1.08-1.28, p < 0.001) and reduces the risk of minor bleeding by 51% (RR, 0.49, 95%CI) %, 0.40-0.59, p ≤ 0.001). CONCLUSIONS The treatment of premalignant lesions of cervical cancer with cold knife reduces the risk of residual disease. Nevertheless, cryotherapy reduces the risk of minor bleeding in the 24 hours after treatment and increases the risk of recurrence of disease and infections.

RESUMEN OBJETIVOS Evaluar la eficacia y seguridad del uso de crioterapia, cono frio o termo-coagulación en comparación con el procedimiento de escisión electroquirúrgica en asa (LEEP) para el manejo de neoplasias intraepiteliales cervicales. MÉTODOS Revisión sistemática de ensayos controlados aleatorizados en mujeres con neoplasia intraepitelial cervical en tratamiento con crioterapia, cono frio, o termo coagulación y LEEP, para estimar su eficacia y seguridad. La búsqueda se realizó en MEDLINE/PUBMED, Registro Cochrane Central de Ensayos Controlados (CENTRAL) y Scopus, hasta setiembre de 2018. RESULTADOS Se identificaron 72 estudios, ocho cumplieron los criterios de inclusión. Cono frio disminuyó el riesgo de enfermedad residual en comparación con LEEP (RR 0,54; IC del 95%, 0,30-0,96, p = 0,04). Crioterapia en comparación con LEEP incrementó el riesgo de recurrencia de enfermedad en un 86,0% (RR 1,86; IC del 95%, 1,16-2,97, p = 0,01) con un tiempo de seguimiento de seis a 24 meses, y de infecciones (RR, 1,17; IC del 95%, 1,08-1,28, p < 0,001); pero redujo el riesgo de sangrado menor en un 51,0% (RR 0,49; IC del 95%, 0,40-0,59, p ≤ 0,001). CONCLUSIONES Cono frio reduce el riesgo de enfermedad residual. Sin embargo, la crioterapia reduce el riesgo de sangrado menor en las 24 horas posteriores al tratamiento e incrementa el riesgo de recurrencia de enfermedad y de infecciones.

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Introducción: La radiocirugía tiene como objetivo proporcionar una herramienta de diagnóstico y tratamiento. Objetivos: Describir los resultados de la conización por radiocirugía en pacientes atendidas en la consulta de patología de cuello uterino de la institución. Métodos: Se realizó una investigación descriptiva de corte transversal en el Hospital General Docente Mártires del 9 de Abril de Sagua la Grande, Villa Clara, Cuba. La población de estudio estuvo conformada por la totalidad de 256 pacientes atendidas en la consulta de patología de cuello uterino que fueron sometidas a conización por radiocirugía, entre enero 2013 y diciembre 2015. Para la recogida de la información se empleó la revisión de documentos y se confeccionó un modelo de recogida de datos. Resultados: El diagnóstico preoperatorio que aportó mayor cantidad de casos fue el NIC III (displasia severa) (78 casos; 30,5 por ciento). Conclusiones: Las lesiones premalignas en el presente estudio comenzaron a aparecer con marcada incidencia a partir de los 20 años y hasta los 49, sobresaliendo el grupo de 30 - 39 años. El aumento en el número de parejas sexuales, así como el comienzo temprano de las relaciones sexuales incrementan el riesgo de padecer lesiones intraepiteliales en el cuello del útero. A partir de los cinco años de iniciada las relaciones sexuales comienzan a aparecer las lesiones intraepiteliales cervicales, el diagnóstico preoperatorio que aportó mayor cantidad de casos fue el NIC III (displasia severa). En los diagnósticos histológicos por sacabocado y cono existió correspondencia en todos los casos(AU)

Introduction: Radiosurgery aims to provide a diagnostic and treatment tool. Objectives: To describe the results of conization by radiosurgery in patients treated in the cervical pathology clinic of the institution. Methods: A descriptive cross-sectional investigation was carried out at Mártires del 9 de abril General Teaching Hospital, in Sagua la Grande, Villa Clara, Cuba. The study population consisted of 256 patients attended in the cervical pathology clinic who underwent conization by radiosurgery, from January 2013 to December 2015. For the collection of the information, the document review was used and a data collection form was made. Results: The preoperative diagnosis that contributed the greatest number of cases was IAS III (severe dysplasia) (78 cases; 30.5 percent). Conclusions: The premalignant lesions in the present study began to appear with a marked incidence from the age of 20 and up to 49, with the group of 30-39 years standing out. The increase in the number of sexual partners, as well as the early sexual intercourse increase the risk of suffering intraepithelial lesions in the cervix. After five years of beginning sexual intercourse, cervical intraepithelial lesions begin to appear, the preoperative diagnosis that contributed the greatest number of cases was IAS III (severe dysplasia). In histological diagnoses by punch and cone correspondence existed in all cases(AU)

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INTRODUCCIÓN. El cáncer cérvico-uterino tiene una fase precursora de larga duración, pues debe pasar por varios estados previos al cáncer invasivo, denominados lesiones intraepiteliales, de bajo y de alto grado, que pueden transformarse en lesiones malignas. La importancia de un diagnóstico oportuno y certero de las lesiones intraepiteliales escamosas de alto grado radica en que, si son tratadas de manera oportuna, son ciento por ciento curables. OBJETIVO. Proporcionar información actualizada sobre el diagnóstico y tratamiento de las lesiones precursoras de cáncer de cérvix y ayudar a los profesionales en la toma de decisiones médicas. MATERIALES Y MÉTODOS. Estudio de revisión de 45 artículos científicos la gran mayoría de la última década y, unos pocos, con datos históricos vigentes sobre lesiones intraepiteliales escamosas de alto grado del cuello uterino. La búsqueda se realizó en MedLine, PLoS y Scielo utilizando los términos tamizaje, neoplasias uterinas, lesiones intraepiteliales escamosas de cuello uterino y tratamiento. RESULTADOS. Los artículos científicos fueron seleccionados por niveles de evidencia 1 y 2, con recomendaciones A y B. Las recomendaciones de inicio de tamizaje han cambiado y el manejo toma en cuenta el riesgo acumulado por tipo de lesión. El tratamiento, en la mayoría de casos, es la escisión y resulta definitivo. CONCLUSIÓN. El diagnóstico sigue siendo cito-colpo-histológico y el tratamiento depende de la edad de la paciente, pudiendo las posibilidades ir de la observación hasta la escisión quirúrgica y, en casos específicos, la histerectomía.

INTRODUCTION. Cervical-uterine cancer has a long-term precursor phase, as it must go through several states prior to invasive cancer, called intraepithelial lesions, low and high grade, which can become malignant lesions. The importance of a timely and accurate diagnosis of high-grade squamous intraepithelial lesions is that, if treated in a timely manner, they are one hundred percent curable. OBJECTIVE. Provide updated information on the diagnosis and treatment of precursor lesions of cervical cancer and assist professionals in medical decision making. MATERIALS AND METHODS. Review study of 45 scientific articles the vast majority of the last decade and, a few, with current historical data on high-grade squamous intraepithelial lesions of the cervix. The search was conducted in MedLine, PLoS and Scielo using the terms screening, uterine neoplasms, squamous intraepithelial lesions of the cervix and treatment. RESULTS. The scientific articles were selected by levels of evidence 1 and 2, with recommendations A and B. The recommendations for starting screening have changed and management takes into account the accumulated risk by type of injury. The treatment, in most cases, is excision and is definitive. CONCLUSION. The diagnosis is still cyto-histological and the treatment depends on the age of the patient, and the possibilities may range from observation to surgical excision and, in specific cases, hysterectomy.

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Introduction: The adequate treatment of cervical intraepithelial neoplasia (CIN) is an important component of cervical cancer prevention programs and its inadequate management may increase the future risk of neoplasia. Objective: To evaluate the role of loop electrosurgical excision procedure (LEEP) conization in the treatment of CIN, in an important state capital in southern Brazil, and to determine the impact on reducing cervical cancer mortality in the next 20 years. Methods: A retrospective cohort study was conducted in patients who underwent CIN treatment from January 1999 to December 2007 at Erasto Gaertner Hospital, analyzing the treatment morbidity and recurrence rate of the disease, using the χ2 test for statistical analysis and p≤0.05. Results: A total of 1,550 women, between 14 and 93 years of age (35±11.42) were evaluated. Recurrence rate was 6.8%. The postoperative complications were 5.8% bleeding, 2% cervical stenosis and 2% infection. The cervical cancer mortality rate decreased from 12 to 3.8/100,000 women and there was an increase in the incidence of the lesion in situ as opposed to the reduction of other clinical stages. Conclusion: LEEP conization was proven to be a highly effective tool in CIN treatment, substantially contributing to the reduction of mortality from cervical cancer, justifying its use in a systematic way in prevention programs.

Introdução: O adequado tratamento da neoplasia intraepitelial cervical é um importante componente dos programas de prevenção do câncer cervical, e seu manejo inadequado pode aumentar o risco futuro de progressão para neoplasia. Objetivo: Avaliar os resultados da cirurgia de alta frequência no tratamento da neoplasia intraepitelial cervical em uma importante capital do Sul do país e o impacto na redução da mortalidade por câncer cervical nos 20 anos subsequentes. Métodos: Estudo tipo coorte retrospectivo de pacientes submetidas a tratamento da neoplasia intraepitelial cervical, no período de janeiro de 1999 a dezembro de 2007, no Serviço de Patologia Cervical do Hospital Erasto Gaertner, Curitiba, Brasil, analisando a morbidade do tratamento e o risco de recorrência da doença utilizando o teste das proporções (χ2 ) e valor p≤0,05, relacionando esses dados às taxas de mortalidade no período dos últimos 20 anos. Resultados: O número de 1.550 pacientes, com idade entre 14 e 93 anos (35,3±11,42). A taxa de recidiva foi 6,8%. As complicações pós-operatórias foram 5,8% de sangramento, 2% de estenose de colo e 2% de infecção. A taxa de mortalidade para câncer de colo na cidade de Curitiba caiu de 12 para 3,8 casos/100mil mulheres, ocorrendo o aumento da incidência da lesão in situ em contraposição à redução dos demais estadios clínicos. Conclusão: a cirurgia de alta frequência mostrou-se um instrumento relevante e de alta eficácia no tratamento da neoplasia intraepitelial cervical, contribuindo de forma efetiva para a redução da mortalidade por câncer de colo uterino, justificando seu uso de maneira sistemática dentro dos programas de prevenção.

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Introduction: The expansion of cytological screening programs for cervical cancer leads to an increase in the proportion of both adenocarcinomas and diagnoses in young women with reproductive intention. Conservative treatment is not fully established. Objective: to report the conservative management and follow-up difficulties of a real case of microinvasive cervical adenocarcinoma in a young woman. Case report: This is a case report of a 23-yearold patient with stage IA1 microinvasive cervical adenocarcinoma related to HPV18. The patient was vaccinated against HPV 16/18 at 16 years of age and conservatively treated. She became pregnant during follow-up with a favorable outcome. Conclusion: We discuss the difficulties and uncertainties regarding follow-up and opportunity for hysterectomy, emphasizing the need for a multidisciplinary approach to make a balanced decision between conservative treatment and oncological safety, as well as mitigate follow-up difficulties in real life.

Introdução: A ampliação dos programas de rastreamento citológico de câncer do colo uterino resulta em aumento na proporção de adenocarcinomas e de diagnósticos em jovens ainda com desejo reprodutivo. O tratamento conservador não está totalmente estabelecido. Objetivo: descrever a condução conservadora e as dificuldades de seguimento em caso real de adenocarcinoma microinvasor do colo em uma jovem. Relato de caso: É relatado o caso de uma paciente de 23 anos com adenocarcinoma microinvasor IA1 do colo uterino relacionado ao HPV 18, mesmo vacinada contra HPV 16/18 aos 16 anos. Foi tratada conservadoramente, com gestação e desfecho favorável. Conclusão: São discutidas as dificuldades e incertezas em relação ao seguimento e à oportunidade para histerectomia, ressaltando a necessidade de abordagem multidisciplinar para decisões equilibradas entre tratamento conservador, segurança oncológica e, ainda, amenizar as dificuldades de seguimento na vida real.

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Introducción. El cáncer de cuello uterino es la segunda causa de muerte más frecuente mundialmente; por ello, existen terapias tanto invasivas como poco invasivas que buscan impactar la supervivencia de la enfermedad. Entre los diferentes métodos de tratamiento se encuentran la radioterapia externa, la braquiterapia, la quimioterapia, la conización, la traquelectomía y la histerectomía radical. Objetivo. Revisar las características de cada uno de los métodos de tratamiento disponibles para el manejo del cáncer de cuello uterino. Metodología. Se realizó una búsqueda, en las bases de datos PUBMED y LILACS, de artículos publicados entre los años 2013 y 2016 que tuvieran como tema central el cáncer de cuello uterino y su tratamiento; luego de aplicar criterios de inclusión y exclusión, se seleccionaron 41 artículos para la revisión. Resultados. Para el manejo del cáncer de cérvix se plantean, como métodos poco invasivos: la conización, con supervivencia a cinco años de 95.1% en cáncer microinvasor; la radioterapia de haz externo, con supervivencia total de 92.2% a cinco años; la quimioterapia, con supervivencia similar a la radioterapia, pero con disminución de la necesidad de cirugía; y la braquiterapia combinada con quimioterapia, que logró respuesta en 64% de pacientes con cáncer estadio IA, IIA y IB. En relación con métodos más invasivos, se encuentran la traquelectomía en cáncer temprano sin compromiso local o a distancia, alcanza supervivencia del 95%, con tasas de embarazo de 50% posteriores al tratamiento y la histerectomía radical, con supervivencia total de 100% a cinco años en cáncer estadio IA2 y IB1, requiriendo algunas veces combinación con otros métodos. Para las técnicas quirúrgicas se han desarrollado nuevos abordajes y variantes. Conclusiones. Los tratamientos en cáncer de cérvix han mostrado resultados alentadores en cuanto a supervivencia, además, la conización y traquelectomía permiten preservar la fertilidad. La quimioterapia, la radioterapia de haz externo y la braquiterapia logran buen control del cáncer de cérvix en estadios tempranos y se pueden usar como coadyuvantes de los métodos quirúrgicos. Sin embargo, la histerectomía radical es el estándar esencial para manejo del cáncer de cérvix, con buenos resultados en supervivencia; sus variantes, además, han logrado disminuir las complicaciones. [Suárez-Cadena FC. Terapéutica del cáncer de cuello uterino, una revisión de la literatura. MedUNAB. 2018;21(1):100-114.doi: 10.29375/01237047.2583].

Introduction. Worldwide, cervical cancer is the second most frequent cause of death, and because of its existence, there are several kinds of therapies that range between invasive to non-invasive ones. The purpose of these procedures is to impact disease survival within the human body. Thus, among those treatment methods used for cervical cancer treatment, we can find the following: external beam radiotherapy, brachytherapy, chemotherapy, cervical conization, trachelectomy, and radical hysterectomy. Objective. To review the characteristics of each one of the available methods for treating cervical cancer. Methodology. Published articles between 2013 and 2016 were collected using the databases PUBMED and LILACS. These articles had as a central topic cervical cancer and its treatment. After applying certain inclusion and exclusion criteria within the research, 41 articles were selected to be reviewed. Results. As non-invasive treatment methods for cervical cancer, the following are proposed: cervical conization method, which has a 5-year survival rate of 95.1% when treating micro-invasive cancer; external beam radiotherapy method, which has an overall 5-year survival rate of 92.2%; chemotherapy method, whose survival rate is similar to external beam radiotherapy method's one, but with a slight diminishing of surgery risk; and finally brachytherapy method, which combined with chemotherapy method achieves 64% of response among patients in cancer stages IA, IIA and IB. On the other hand, more invasive treatment methods are presented as follows: trachelectomy method when treating early cancer stages (with no local involvement or distant spreading) reaches a survival rate of 95% and a post-treatment pregnancy rate of 50%, and radical hysterectomy method has a 5-year survival rate of 100% among patients in cancer stage IA2 and IB1, in spite in some occasions this method requires to be combined with other treatment techniques. New therapeutic approaches and variations have been developed for surgical techniques. Conclusions.Cervical Cancer treatments have shown promising results regarding survival rate and in some procedures, such as conization and trachelectomy, preservation of fertility rate. Methods such as chemotherapy, external beam radiotherapy, and brachytherapy have a great control of cervical cancer in early stages, and they can also be used as adjuvant therapies for surgical interventions. Nonetheless, radical hysterectomy is the standard and essential medical procedure for managing cervical cancer. This method has shown good results regarding survival rates and its variants have helped to diminish associated complications. [Suárez-Cadena FC.Cervical cancer therapeutics: a literature review. MedUNAB. 2018;21(1):100-114.doi: 10.29375/01237047.2583]

Introdução. O câncer de colo do útero é a segunda causa de morte mais frequente no mundo e por isso, existem terapias invasivas e minimamente invasivas que buscam impactar na sobrevivência da doença. As principais opções de tratamento para o câncer de colo do útero são: a radioterapia externa, a braquiterapia, a quimioterapia, a conização, a traquelectomia e a histerectomia radical. Objetivo. Revisar as características de cada um dos métodos disponíveis para o tratamento do câncer de colo do útero. Métodos. Pesquisa feita nas bases de dados PUBMED e LILACS, de artigos publicados entre 2013 e 2016 com o assunto principal: tratamento do câncer de colo do útero e tratamiento. Foram selecionados 41 artigos para revisão, após a aplicação dos critérios de inclusão e exclusão. Resultados. Para o tratamento do câncer de colo de útero, os seguintes métodos são considerados minimamente invasivos: a conização, com sobrevida em cinco anos equivalente a 95,1% no câncer microinvasor; a radioterapia externa, com sobrevida total de 92,2% em cinco años; a quimioterapia, com sobrevida semelhante à radioterapia, mas com diminuição da necessidade de cirurgia; e a braquiterapia combinada com quimioterapia, que obteve resposta em 64% dos pacientes com estádio IA, IIA e IB. Em relação aos métodos mais invasivos, a traquelectomia no câncer precoce sem comprometimento 102local, ou à distância, atinge 95% de sobrevida, com 50% de taxas de gestação após o tratamento e histerectomia radical, com sobrevida total de 100% a cinco anos no estádio IA2 e IB1, requerendo às vezes combinação com outros métodos. Para técnicas cirúrgicas, novas abordagens e variantes foram desenvolvidas. Conclusões. Os tratamentos de câncer de colo do útero mostraram resultados encorajadores em termos de sobrevida, além disso, a conização e traquelectomia permitem preservar a fertilidade. A quimioterapia, a radioterapia externa e a braquiterapia conseguem um bom controle do câncer de colo do útero em estádios iniciais e podem ser usadas como coadjuvantes dos métodos cirúrgicos. Entretanto, a histerectomia radical é o padrão essencial para o tratamento de câncer de colo do útero, com bons resultados na sobrevida; suas variantes, além disso, conseguiram reduzir as complicações. [Suárez-Cadena FC.Terapêutica do câncer de colo do útero, uma revisão de literatura. MedUNAB. 2018;21(1):100-114.doi: 10.29375/01237047.2583].

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Resumen OBJETIVO: Investigar las posibles causas de los conos blancos, establecer estrategias para disminuir su incidencia y desarrollar protocolos de seguimiento. MATERIALES Y MÉTODOS: Estudio observacional, retrospectivo, de casos y controles. Se incluyeron las pacientes a quienes se efectuó una conización en el Hospital Universitario La Paz. Las variables analizadas más importantes fueron: anatomía patológica de la pieza y su relación con la biopsia y citologías previas, longitud del cono, presencia o no de artefacto y de cervicitis. Para el análisis estadístico se utilizaron: χ2, prueba exacta de Fisher, t de Student, U de Mann-Whitney, Kruskal-Wallis y Kolmogorov-Smirnov. RESULTADOS: Se integraron dos grupos: 371 conos positivos (85.9%) y 61 negativos (14.1%), con diferencias estadísticamente significativas en la citología, colposcopia y biopsia. Hubo mayor porcentaje de lesiones de menor grado en las pacientes con conización blanca. La longitud del cono fue menor en el grupo de análisis y en éste también se observó mayor porcentaje de cervicitis y artefactos. CONCLUSIONES: Las causas de lesión residual luego de una conización son variadas y difíciles de demostrar. Las pacientes con citología anómala e inflamación o atrofia deben recibir tratamiento para evitar falsos positivos y mejorar la técnica quirúrgica para impedir artefactos.

Abstract OBJECTIVES: to investigate the possible causes of the negative cones, to establish strategies to reduce their incidence and to develop monitoring protocols. MATERIALS AND METHODS: This is a retrospective observational cases and controls study of 432 conizations made in the Hospital Universitario La Paz (HULP) between 2013 and 2015. The most important analysed variables were the pathological anatomy of the piece and its relationship with the biopsy and previous cytology, the cone length, as well as the presence and artefact and cervicitis. The analysis it was used Chi - Square and Fisher´s test, T-Student, Mann Whitney U, Kruskal-Wallis and Kolmogorov- Smirnov. RESULTS: There are two groups: 371 positive (85,9%) and 61 negative cones (14,1%). We find statistically significant differences in the cytology, colposcopy and biopsy pre-conization, finding a major percentage of injuries of lesser degree in the patients with negative cone. The length of the cone was lower in the analysis group and in this we also observed a greater percentage of cervicitis and artefacts. CONCLUSIONS: The causes that make the remaining injury not appear after a diagnosed and/or therapeutic conization are a wide variety and difficult to prove. We should try to treat the patients with inflammation or atrophy to avoid false positives in the cytology and biopsy, improve the surgical technique to avoid artefacts and perform conservative management of low-risk injuries.