Invasive cancer of the cervix after treatment for cervical intraepithelial neoplasia (CIN) is becoming more important, as screening reduces the incidence of invasive disease. The rate of invasive cervical or vaginal cancer following treatment for CIN in UK remains elevated for at least 8 years. The aim of our study was to determine from international data how long this rate remains elevated and whether the rate of invasive disease reflects the rate of posttreatment CIN. The aim was to determine why the rate of invasive disease does not fall. A search of Medline and a secondary search of cited references identified 1,848 articles referring to the success rate of the treatment of CIN. Only 26 cohorts from 25 articles met all the inclusion criteria. The policy in these was to perform at least annual smears. After the first year following treatment for CIN, the rate of invasive disease remained about 56 per 100,000 woman years until at least 20 years after treatment. This rate is~2.8 times greater than expected. In contrast, the risk of posttreatment CIN declined steadily with time to about 190 per 100,000 women in the 10th year. Although the posttreatment rate of CIN falls with time, the rate of invasive disease remains static. It seems likely that this is due to diminishing compliance with follow-up. Women should be encouraged to persevere with annual smears for at least 10 years after their treatment as this may offer them the best chance of detecting recurrence at a treatable stage. ' 2005 Wiley-Liss, Inc.Key words: cervical neoplasms; cervical intraepithelial neoplasia; treatment; follow-up; patient compliance Invasive cancer of the cervix occurring after treatment for cervical intraepithelial neoplasia (CIN) is becoming more important, as screening reduces the overall incidence of invasive disease. In 1997, a multicentre UK study of 44,699 women years of followup after conservative treatment of CIN showed that the cumulative rate of invasion after 8 years was 5.8 per 1,000 women and that the rate remained the same throughout the 8-year period such that these women remained at~5 times greater risk than the general population.1 The second edition of the NHS Cervical Screening Programme Guidelines, 2 published in the same year, described the controversy surrounding the optimum duration of annual cytology testing after the treatment of CIN. It also referred to the importance of confirming that the rate of invasive disease did not fall and of investigating the reasons for this continuing high risk.The present study was commissioned by NHS Cervical Screening Programme to undertake an analysis of long-term follow-up studies of women treated for CIN. The first objective was to determine from international data how long the rate of invasive cervical or vaginal cancer following treatment for CIN remains elevated. The second objective was to establish whether the rate of invasive disease was a reflection of the rate of posttreatment CIN. The aim was to investigate the reasons for the continuing high risk of invasive dis...

Pavlakis K, Messini I, Vrekoussis T, Panoskaltsis T, Chrysanthakis D, Yiannou P & Voulgaris Z
(2011) Histopathology 58, 966–973
MELF invasion in endometrial cancer as a risk factor for lymph node metastasis Aim:  To investigate whether the microcystic, elongated and fragmented (MELF) pattern of myometrial invasion encountered in certain endometrioid endometrial carcinomas can be considered as a risk factor for lymph node metastasis. Methods and results:  A total of 351 cases of total abdominal hysterectomy and bilateral salpingo‐oophorectomy with/without lymphadenectomy or lymph node sampling, performed for endometrioid endometrial adenocarcinoma, were included in this study. The existence of MELF invasion, vascular invasion, fibromyxoid stromal reaction and lymph node metastasis were recorded. Immunohistochemistry for endothelial and epithelial markers was performed on selected cases. MELF invasion was identified in 20 (10.81%) and 13 cases (13.13%) treated without and with lymphadenectomy, respectively. All these cases were either well or moderately differentiated carcinomas, stages IA–II (without considering lymph node status). Positive lymph nodes were detected in seven of 13 MELF‐positive (53.84%) and six of 86 MELF‐negative cases (6.97%) This observation was statistically significant. Of the seven MELF‐positive tumours with lymph node metastasis, three cases exhibited intravascular tumour emboli while four showed a fibromyxoid stromal reaction. Conclusion:  MELF pattern invasion was found to be related statistically to lymph node metastasis. Nevertheless, further studies are needed in order to evaluate the clinical significance of this observation.

Objectives To document the frequency of pathology in women who complain of postcoital bleeding. To determine whether negative cervical cytology excludes serious pathology in women with postcoital bleeding. To determine whether postcoital bleeding increases the risk of serious pathology in women with an abnormal smear.Design A retrospective study.Setting A university teaching hospital. Population 314 women with postcoital bleeding seen in the gynaecology service from ®rst January 1988 to 31 December 1994. Methods Women were identi®ed from the computerised records of the colposcopy service and copies of correspondence, which was routinely retained on computer. The latter was searched for the text strings coital and intercourse. Main outcome measure Histopathological diagnosis.Results Twelve women (4%) had invasive cancer: 10 were cervical or vaginal cancers and two endometrial cancers. Eight of the 10 cervical or vaginal cancers were clinically apparent. Four women of these 10 had had a normal smear before being referred for further investigation of postcoital bleeding. Two of these cancers were visible only with the aid of the colposcope. Thus, 0.6% of women attending a gynaecology service with postcoital bleeding, a normal looking cervix and a normal smear had invasive cancer of the cervix. Cervical intraepithelial neoplasia were found in 54 women (17.%) and 15 women (5%) had cervical polyps. Nineteen of the 63 women (30%) with signi®cant pathology had a normal or in¯ammatory cervical smear. No explanation for the postcoital bleeding was found in 155 women (49 %).Conclusions Although invasive cancer is rare in women with postcoital bleeding, it is much commoner than in the general population. It seems likely that cervical intraepithelial neoplasia is also associated with postcoital bleeding, perhaps because the fragile cervical epithelium becomes detached during intercourse. Postcoital bleeding should continue to be regarded as an indication of high risk for invasive cervical cancer and for cervical intraepithelial neoplasia. Prompt referral to a colposcopy clinic is indicated, but most women with postcoital bleeding will have no serious abnormality.

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