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Biomedical subjects

D M Luesley

Publications and source records attributed to D M Luesley.

At least 19 recordsLinked to original sources
PubMed2006

Topical tacrolimus in the management of lichen sclerosus.

The effective management of vulval lichen sclerosus (LS) currently depends upon the use of topical steroids and emollients. There are concerns with regard to the long-term toxicity of potent steroids and therefore is a need to consider effective alternatives. Immunomodulatory macrolactams offer an alternative to steroids in the management of some other inflammatory skin disorders and it would seem reasonable therefore to assess their activity in LS. This pilot study of 16 histologically confirmed cases of LS suggests that macrolactams have a positive pharmacological effect.

Administration, Topical↗
PubMed2005

A systematic review of the accuracy of diagnostic tests for inguinal lymph node status in vulvar cancer.

OBJECTIVE: To determine the accuracy of minimally and non-invasive tests to assess the groin node status in squamous cell vulvar cancer. METHODS: A systematic review of published research from 1979 to 2004 that compares the results of tests to determine groin node status with histology at inguinofemoral lymphadenectomy was made. Studies included in the review were those that compared the index test to the standard surgical intervention of inguinofemoral lymphadenectomy and allowed the construction of two-by-two tables. From these tables, sensitivity, specificity, and the likelihood ratios (with 95% confidence intervals) were reported and, where feasible, meta-analysis was used to pool results for each test separately. Sentinel node biopsy using technetium-99m-labelled nanocolloid ((99m)Tc) had a pooled sensitivity and negative LR of 97% (91-100 95% CI) and 0.12 (0.053-0.28 95% CI), respectively, and was the most accurate test reviewed. CONCLUSION: Five diagnostic tests were identified in a total of 29 studies (961 groins). Although the studies were small and the design often poor, this represents the best summary of the data to date. Sentinel node identification using (99m)Tc appeared to be the most promising test for accurately excluding lymph node metastases in squamous cell vulvar cancer and potentially reducing the radicality of surgery. Its efficacy as a tool in reducing the need for radical surgery and associated patient morbidity without reducing survival needs further assessment probably in a randomised control trial.

Female↗
PubMed2005

Is radical hysterectomy for early stage cervical cancer an outdated operation?

Radical hysterectomy and pelvic lymphadenectomy is the standard surgical treatment for early stage cervical cancer. This operation is well recognised as having a higher morbidity and mortality rate than a simple hysterectomy. We studied the histology results of 131 patients who had standard surgery for cervical cancer to ascertain if a radical hysterectomy was required for adequate treatment. Of 110 (84%) patients with negative pelvic lymphadenopathy, only 9 (8%) had positive parametrial histology and all required adjuvant therapy independent of their parametrial histology. This study confirms that a less radical hysterectomy and pelvic lymphadenectomy provides adequate treatment and allows us to consider a more conservative, minimal access approach to the management of these patients.

Carcinoma↗
PubMed2001

Adenocarcinoma in situ of the cervix-controversies in diagnosis and treatment.

Adenocarcinoma in situ (AIS) of the uterine cervix is a rare condition. Pap smear screening is unsatisfactory, and the disease has no morphologic reliable colposcopic features. Diagnosis is often made by chance during the treatment of squamous pre-invasive disease, which commonly coexists with AIS. Although the entire endocervical canal can be the site of disease, most lesions lie within 1 cm of the squamocolumnar junction. Skip lesions are rare, making fertility-sparing surgery a possibility under certain conditions. Recurrent disease occurs in 14% of cases when cone margins are free of disease and rise to more than 50% if the margins are involved. The method of conization is immaterial provided a large enough specimen is taken and that the endocervical margins can be evaluated by the pathologist. Follow-up of conservatively managed women is not defined; however, we recommend that regular endocervical cytology be performed in addition to conventional cytology and colposcopy.

Journal Article↗
PubMed2000

Management guidelines for women with normal colposcopy after low grade cervical abnormalities: population study.

OBJECTIVES: To develop an evidence based protocol for the follow up of women with low grade cervical abnormalities for whom treatment is not immediately indicated. DESIGN: Population outcome study. SETTING: Colposcopy clinic of an inner city teaching hospital. PARTICIPANTS: 566 women with low grade cytological abnormalities who were not treated at a first visit to the colposcopy clinic, followed up for a total of 881 years. MAIN OUTCOME MEASURES: Resolution of abnormalities, persistence of disease, and treated disease. RESULTS: Abnormalities resolved in 306 (54.1%) women, whereas 138 (24.4%) had persistent disease and 122 (21.5%) were subsequently treated. Colposcopic opinion, smear test results, age, smoking history, and number of pregnancies were all significantly related to outcome. Logistic regression analysis produced a model that correctly identified 70% of women whose abnormalities resolved. Only 23 of 295 women (7.8%) with a normal cervix on colposcopy and a smear without dyskaryosis at a first visit were treated by the end of the observation period. CONCLUSIONS: Women referred with low grade cytological abnormalities who have a normal cervix on colposcopy and a negative or borderline repeat smear test result may be discharged from the colposcopy clinic. We propose a follow up protocol that could safely avoid unnecessary visits to a clinic.

Adult↗
PubMed1999

Histologic and immunologic associations of an HPV16 variant in LoSIL smears.

BACKGROUND: Human papillomavirus type 16 variants have been described and may have different biologic activities: this has implications for the design of HPV vaccines. OBJECTIVES: The aim of this study was to see if the HPV16 variant E-G 131 can be detected in women with preinvasive disease and to consider the histological and immunological implications of such infection. DESIGN: A prospective observational cross-sectional study on a cohort of women with minor cervical cytological abnormalities was performed. METHODS: Samples were tested for HPV DNA by polymerase chain reaction and restriction enzyme digestion. Blood samples were tested for antibodies to HPV16 virus-like particles (VLP) and to determine class I HLA types. Women found to have abnormal colposcopy were treated by large-loop excision of the transformation zone on a see-and-treat basis. RESULTS: Two hundred forty-one women were included in the study. Infection with the variant was detected in 20. 9% of cases and was not associated with any specific HLA type. These cases were more likely to have high-grade CIN than those with wild-type HPV16 or no HPV16 (chi2 = 18.85, P < 0.001). There were significant differences in seropositivity to HPV16 virus-like particles between the three groups (chi2 = 32.43, P < 0.001). CONCLUSIONS: The E-G 131 variant may have increased oncogenic potential by evading host immune responses, but its identification is only weakly predictive of high-grade disease in stepwise logistic regression. The lack of seropositivity to HPV16 VLP has implications for the design of prophylactic vaccines based on VLP to HPV16.

Adult↗
PubMed1999

A study of the follow up patterns of women treated for CIN 2 and 3 before and after the introduction of the 1992 guidelines.

OBJECTIVE: To analyse the five year cytology follow up data after discharge on women treated for histologically proven cervical intraepithelial neoplasia (CIN) 2 and 3. To assess whether the introduction of the 1992 Guidelines for Clinical Practice and Programme Management affected follow up patterns. To identify who was lost to follow up and for what reasons. DESIGN: A retrospective cohort study of cervical cytological follow up data from 186 women treated for CIN 2 and 3. SETTING: Primary care services, West Midlands, United Kingdom. POPULATION: One hundred and eighty-six women with CIN 2 or 3 treated with large loop excision of the transformation zone at the City Hospital, Birmingham, in whom the first follow up smear at six months was normal. The women were divided into two groups: Group 1 consisted of women treated before the introduction of the Guidelines (1988-1990), and Group 2 consisted of women treated at the time of the introduction of the Guidelines in 1992. INTERVENTION: Introduction of the 1992 Guidelines for Clinical Practice and Programme Management. MAIN OUTCOME MEASURES: To determine the number of follow up smears each woman had over a five year period, to determine the number of women who had the recommended number of follow up smears, and to identify the number of women lost to follow up. RESULTS: The median (interquartile range) number of smears in Group 1 was five (four to six) and in Group 2 was four (four to five). A similar proportion of women in both groups subsequently had abnormal smears (15% and 13.6%). Only one woman required further treatment. 22% of women in Group 1 and 10.2% of women in Group 2 had the correct number of smears to fulfil the 1992 Guidelines. There were 21 women (11.3%) who only had one smear following discharge from the clinic in the five year follow up period. CONCLUSIONS: The data from both cohorts shows follow up to be poor, and the introduction of the 1992 Guidelines has yet to result in an improvement in follow up patterns. The absence of a national cervical cytology database means that surveys of cytology follow up data will continue to be difficult due to the problems of data collection from numerous health authorities and the mobility of women in this age group.

Adult↗
PubMed1999

Lichen sclerosus of the vulva. Long-term steroid maintenance therapy.

OBJECTIVE: To assess the efficacy of graduated topical steroids for long-term maintenance therapy for vulvar lichen sclerosus. STUDY DESIGN: A prospective observational study was performed in the Gynaecological Oncology Department, City Hospital, Birmingham, U.K. Fifty-four patients were recruited for the study. The diagnosis was confirmed with histopathologic examination. After confirmation of the diagnosis, patients were started on a diminishing regimen of topical steroid. RESULTS: Of the 54 patients in the study, 51 responded to the steroid regimen, and three did not. CONCLUSION: The graduated topical steroid regimen has a high response rate and takes a relatively short time to achieve, justifying the use of graduated topical steroids for this condition. Graduated dose reduction allows the majority of patients to remain in asymptomatic remission and minimize steroid exposure.

Administration, Cutaneous↗
PubMed1999

Response of vulvar lichen sclerosus and squamous cell hyperplasia to graduated topical steroids.

OBJECTIVE: To determine whether symptomatic remission could be obtained equally effectively in patients with vulvar lichen sclerosus, squamous cell hyperplasia or mixed disease in response to a standardized course of graduated topical steroids. STUDY DESIGN: A retrospective analysis of 137 patients with biopsy-proven lichen sclerosus (84), squamous cell hyperplasia (42) or mixed disease (11) treated between 1990 and 1997 with a standard, three-month regimen of graduated topical steroids was carried out. Presence or absence of symptoms and side effects of treatment were recorded three and six months following induction of the initial graduated topical steroid regimen. RESULTS: On completion of the graduated topical steroid course, 59% of patients were asymptomatic (P = .035), and at six months, 58% were asymptomatic (P = .11). Remission of symptoms was more easily achieved in patients with lichen sclerosus as compared to patients with squamous cell hyperplasia and mixed disease at both three and six months (P = .09 at three and P = .035 at six). Four cases of local reactions to the steroids were recorded, as were two cases of vulvar malignancy. CONCLUSION: Symptomatic remission was significantly easier to achieve in patients with vulvar lichen sclerosus as compared to those with squamous cell hyperplasia following treatment with graduated topical steroids.

Administration, Topical↗
PubMed1998

Urological problems and the treatment of gynaecological cancer.

This article reviews the recent literature on urological complications in gynaecological oncology. In particular it focuses on the current controversies in the management of urinary fistulae and reconstruction or urinary diversion after pelvic exenteration.

Female↗
PubMed1997

Observer variability among colposcopists from the West Midlands region.

OBJECTIVE: To assess variation in diagnoses and management decisions among colposcopists when presented with cervical images; to see the impact of the referral cytology report on diagnostic accuracy. DESIGN: A two-part video questionnaire study. PARTICIPANTS: Colposcopists from West Midlands Region. METHODS: Twenty cervical images displaying a range of transformation zones from normal through varying abnormalities up to cervical intraepithelial neoplasia (CIN) grade 3 were shown on video tape together with basic patient information. Two sets of videos were made, the second being identical to the first other than including the referral cytology. Participants recorded their diagnoses and management decisions on prepared questionnaires. The two sets of videos were viewed several weeks apart. RESULTS: Completed questionnaires to both videos were received from 30 colposcopists. Diagnostic accuracy improved with knowledge of the cervical cytology result in cases of CIN 2/3 (chi 2 = 19.45, P < 0.0001) but not where the histology was CIN 1 or less (chi 2 = 2.64, P = 0.10). Overall interobserver agreement improved slightly from kappa = 0.169 to kappa = 0.212 when the cytology was revealed. While only 2.6% of cases of CIN 2/3 would have been under-managed after the second questionnaire, 37.5% cases where the abnormality did not amount to CIN would have been overtreated. CONCLUSION: There is considerable inter-observer variability and variation in diagnostic accuracy in scoring cervical images particularly at the lower end of the spectrum of abnormality which has the potential to lead to over-treatment. We rely considerably on the cervical cytology result in forming a diagnosis. We recommend that a see-and-treat approach be abandoned when the referral smear shows minor abnormalities. The study has implications for both training and audit in colposcopy.

Colposcopy↗
PubMed1997

Video colpography: a new technique for secondary cervical screening.

OBJECTIVE: To assess the diagnostic accuracy of a new technique of cervical imaging and to consider its potential as a secondary cervical screening method. DESIGN: A prospective cross-sectional study with each case acting as its own control, comparing video colpography with colposcopy. SETTING: University of Birmingham colposcopy clinics, City Hospital and Birmingham Women's Hospital. PARTICIPANTS: Fifty women referred for colposcopy. INTERVENTIONS: The women had a video colpogram recording made prior to colposcopy. MAIN OUTCOME MEASURES: The proportion of technically suitable colpograms obtained and the level of agreement between colposcopist and video screener. RESULTS: The images were satisfactory or good in 94% cases, and there was a very high level of agreement between colposcopist and video screener (kappa = 0.79). If the technique had been used in a primary health care setting as a secondary screening method for women with low grade cervical smear abnormalities, 61% would have avoided referral for colposcopy. CONCLUSIONS: Video colpography is an accurate, portable and quick method of cervical imaging. It combines the simplicity of a video camera with the versatility of computerised digital imaging and has great potential in the fields of teaching, audit and screening of low grade smear abnormalities.

Colposcopy↗
PubMed1997

Is loop excision adequate primary management of adenocarcinoma in situ of the cervix?

OBJECTIVE: To assess the efficacy of cervical loop excision as primary management of adenocarcinoma in situ. DESIGN: A two-centre retrospective study. SETTING: Birmingham and Midlands Hospital for Women and City Hospital NHS Trust. POPULATION: Nineteen women with a histological diagnosis of adenocarcinoma in situ (high grade CIGN) of the cervix made on diathermy loop excision. MAIN OUTCOME MEASURES: Presence or absence of adenocarcinoma in situ at loop specimen margins, results of cervical cytological examinations following loop excision, results of histopathological assessment of any surgical specimens taken after initial loop excision. RESULTS: Of the 19 women with confirmed adenocarcinoma in situ on loop excision, the median age was 31, and 8 (42%) were nulliparous. The median follow up of these women was 19 months. Eleven women were treated by loop excision alone and have had normal follow up to 18 months. Five women have undergone further surgical procedures, four had a hysterectomy and one had a repeat loop excision. No residual disease was found in any of these surgical specimens, confirming that loop excision was adequate primary management of the disease. Three women have had abnormal endocervical follow up cytology suggestive of residual disease. One of these three women may represent a case of residual endocervical disease. Excision margins of the loop specimen were not involved by adenocarcinoma in situ in 11 women. However, excision margin status of the loop specimen did not appear to be predictive of residual disease. CONCLUSIONS: Our small retrospective study suggests that diathermy loop excision of the cervix is adequate primary management of adenocarcinoma in situ of the cervix. Cytological and colposcopic follow up, including cytobrush endocervical cytological sampling and long term follow up, is recommended in these women.

Adenocarcinoma↗
PubMed1997

Randomised trial of immediate versus deferred treatment strategies for the management of minor cervical cytological abnormalities.

OBJECTIVE: To compare immediate and deferred treatment in women with cervical smears showing borderline nuclear abnormalities or mild dyskaryosis. DESIGN: Prospective randomised trial. SETTING: Colposcopy clinics at Birmingham and Midland Hospital for Women and the City Hospital NHS Trust, Dudley Road, Birmingham. PARTICIPANTS: Four hundred and thirty-five women with minor cytological abnormality younger than 35 years of age, of whom 353 were randomised to immediate treatment or deferred treatment. MAIN OUTCOME MEASURES: Comparison of histologies in the subsequent two years in the immediate and deferred treatment groups. RESULTS: Thirty-six women (21%) defaulted from follow up. The percentage of high grade abnormalities (CIN II and III) in the deferred treatment arm at two years is similar to that in the immediate treated arm at first colposcopy (25% vs 24%). Cytology failed to pick up two cases of CIN III and there was one case of early invasive carcinoma at the six month follow up. If treatment is deferred, the proportion with CIN I is almost halved (25% vs 13%); the proportion with koilocytic atypia is slightly reduced (51% vs 42%) and the proportion with no abnormality is substantially increased (0.6% vs 20%). CONCLUSION: Immediate referral and a select-and-treat management strategy of all women with any degree of dyskaryosis is recommended based on the case of invasive cervical cancer, high default rate and the failure of cytology to pick up two cases of CIN III.

Adolescent↗
PubMed1996

Vulvar intraepithelial neoplasia: long term follow up of treated and untreated women.

OBJECTIVE: To investigate the long term outcome of patients with vulvar intraepithelial neoplasia. DESIGN: A retrospective study using information obtained from patient casenotes. SAMPLE: One hundred and thirty-three women with a primary diagnosis of vulvar intraepithelial neoplasia (VIN), identified during a 15-year period. RESULTS: The diagnosis of vulvar intraepithelial neoplasia increased throughout the study period. Human papilloma virus changes were noted in 104 patients (78%); these women were significantly younger than those without (P < or = 0.001). Nineteen (14%) were managed by observation or medical treatment and the remainder by surgical methods. Histological or symptomatic recurrence after surgical treatment occurred in 55 (48%). When disease recurred, it usually did so within four years of treatment. Recurrence was more common following laser vapourisation than after local excision (75% vs 40%; P < or = 0.01). Progression to invasive disease occurred in nine patients (7%), none of whom were in the group being observed. Four deaths occurred in this group, three from gynaecological malignancies of the lower genital tract. CONCLUSION: Patients with vulvar intraepithelial neoplasia require long term follow up, and the risk of invasion may be higher than previously thought. Surgical treatment when required should be by excisional rather than ablative methods in most instances. In selected cases it is also possible to safely manage patients by more conservative methods.

Adolescent↗
PubMed1996

Vulvar intraepithelial neoplasia with superficially invasive carcinoma of the vulva.

OBJECTIVE: To investigate the long-term outcome of patients presenting with vulvar intraepithelial neoplasia (VIN) with superficially invasive carcinoma of the vulva (SICa). DESIGN: A retrospective study using information obtained from patient case notes. SAMPLE: Twenty-six women found at presentation to have VIN in association with superficially invasive carcinoma were identified during a 15-year period. RESULTS: Pruritus vulvae was the most frequent presenting symptom in 18 patients (69%). Sixteen women (61.5%) had multiple symptoms. Features noted at vulvar examination were variable and none were pathognomonic of either VIN or of superficial invasion. All patients had VIN 3 in association with a superficially invasive carcinoma. Histological changes associated with human papillomavirus were found in 19 (73%) women. Half had a co-existent or previous abnormality of the lower genital tract. Local excision was the most frequent initial treatment (n = 9 [35%]). Mean follow up time was 65 months (range 12-174). Disease persisted after primary treatment in five women (19%). Both histological recurrence (of either VIN or SICa) or symptomatic recurrence occurred in 10 patients (38%). All patients who experienced recurrence did so within 36 months of treatment. Overall, 12 patients (46%) relapsed (histological or symptomatic recurrence); the mean time was 18 months. Fourteen patients (54%) were managed satisfactorily by their initial treatment. One patient died of recurrent cervical cancer. Three progressed to frankly invasive disease: two (aged 31 and 39 years) with carcinoma of the vulva and one aged 34 years with carcinoma of the perianal margin. All are alive and well after treatment. One patient had recurrence of superficially invasive carcinoma treated by local excision with no further problems. No episode of metastasis via lymphatic or vascular channels has been seen. CONCLUSIONS: Patients with superficially invasive carcinoma of the vulva may be safely treated by local excisional methods without recourse to lymphadenectomy. Relapse after primary treatment is common, and there appears to be a significant risk of progression to frankly invasive carcinoma.

Adult↗