Genital variant of folliculosebaceous cystic hamartoma

BACKGROUND

Clinically, folliculosebaceous cystic hamartomas (FSCH) present as skin-colored papulonodules of the face, especially the nose. This is in contrast to sebaceous trichofolliculomas which often present as depressed ostia containing terminal or vellus hairs.

OBSERVATION

A 34-year-old female had a skin-colored multinodular plaque of the labia majora that demonstrated the histologic findings of an FSCH. These included an irregularly shaped central cystic structure surrounded by multiple sebaceous lobules as well as a fibrous stroma. The epithelial-lined cyst contained no hair shafts.

CONCLUSION

A single case report of a scrotal lesion with a similar clinical appearance and histologic findings has previously been described as a genital variant of sebaceous trichofolliculoma. However, the report predated the initial description of FSCH. In our opinion, both cases represent examples of the genital variant of FSCH.

Treatment of acyclovir-resistant herpetic ulceration with topical foscarnet and antiviral sensitivity analysis

BACKGROUND

Herpes simplex virus (HSV) can produce persistent mucocutaneous disease in patients with the acquired immunodeficiency syndrome (AIDS). In this case report, we evaluate the efficacy, safety and viral resistance after topical foscarnet in severe genital ulceration due to acyclovir-resistant HSV-2.

CASE REPORT

A 45-year-old African woman was known for an HIV infection with severe immunosuppression (CD4 <100/mm3). She had received a long-term prophylaxis with acyclovir (400 mg b.i.d.) for a recurrent genital herpes. Few weeks after stopping this prophylaxis, she developed large genital ulcerations progressing despite valacyclovir treatment (1,000 mg t.i.d.). Cultures were positive for HSV-2, resistance to acyclovir was shown by the plaque reduction assay and topical foscarnet was tried. Treatment consisted of a 20-min application of topical foscarnet 2.4% twice a day. Dramatic improvement was observed with rapid antalgia, and cicatrization of the genital ulcerations was observed after 50 days. HSV could not be detected on the mucosal surface. Initially, HSV-2 was resistant to acyclovir but sensitive to foscarnet. After 1 month of topical treatment, HSV-2 became sensitive to acyclovir and was still sensitive to foscarnet. Finally, after 6 weeks of treatment, no virus could be detected by culture.

CONCLUSION

Topical foscarnet (2.4%) is a convenient treatment for chronic genital herpes. Resistance to acyclovir disappears few weeks after stopping this drug and sensitivity to foscarnet persists during the 50 days of treatment.

Is measuring the posterior urethrovesical angle of clinical value for controlling pelvic organ Prolapse? Retrospective analysis of 107 postoperative cases

Vaginal total hysterectomy with vaginal plasty was performed in 107 patients with pelvic organ prolapse. The posterior urethrovesical angle (PUVA) was measured by chain urethrocystography. Bladder capacity, residual and incontinence urine volume were measured before and after surgery, and the data obtained were analyzed in relation to postoperative improvement and recurrence of urinary dysfunction. There were no significant differences between the background of patients with dysuria, incontinence, a mixture of dysuria and incontinence, and neither of these symptoms. Postoperative incontinence and residual urine volume decreased in all groups. However there was no correlation between the preoperative PUVA and either incontinence or residual urine volume. Measurement of PUVA was neither helpful in making the diagnosis nor predictive of the recurrence of urinary dysfunction.

In situ analysis of the evolution of the primary immune response in murine Chlamydia trachomatis genital tract infection

Adaptive immune responses contribute to the resolution of Chlamydia trachomatis genital tract infection and protect against reinfection, but our understanding of the mechanisms of those protective responses is incomplete. In this study, we analyzed by in situ immunohistochemistry the progression of the inflammatory and cytokine responses in the genital tracts of mice vaginally infected with C. trachomatis strain mouse pneumonitis. The cellular inflammatory response was characterized by an initial elevation in myeloid cells in the vagina (day 3) and uterine horns (day 7), followed by a marked rise in the number of T cells, predominantly CD4(+) cells. CD8(+) T cells and CD45R(+) B cells were also detected but were much less numerous. Perivascular clusters of CD4(+) T cells, which resembled clusters of T cells seen in delayed-type hypersensitivity responses, were evident by 2 weeks postinfection. Following the resolution of infection, few CD8(+) T cells and CD45R(+) B cells remained, whereas numerous CD4(+) T cells and perivascular clusters of CD4(+) T cells persisted in genital tract tissues. Interleukin-12 (IL-12)- and tumor necrosis factor alpha (TNF-alpha)-producing cells were observed in vaginal tissue by day 3 of infection and in uterine tissues by day 7. Cells producing IL-4 or IL-10 were absent from vaginal tissues at day 3 of infection but were present in uterine tissues by day 7 and were consistently more numerous than IL-12- and TNF-alpha-producing cells. Thus, the evolution of the local inflammatory response was characterized by the accumulation of CD4(+) T cells into perivascular clusters and the presence of cells secreting both Th1- and Th2-type cytokines. The persistence of CD4(+)-T-cell clusters long after infection had resolved (day 70) may provide for a readily mobilizable T-cell response by which previously infected animals can quickly respond to and control a secondary infectious challenge.

Genital diseases in the peruvian dusky dolphin (Lagenorhynchus obscurus)

Ovarian cysts and one ovarian tumour, uterine tumours, vaginal calculi, abscesses of the broad ligament or undetermined testicular lesions were observed in 25 out of 502 female and male dusky dolphins (Lagenorhynchus obscurus) caught off Peru in 1985-1987 or 1993-1994. Tentative or definitive diagnoses included Graafian follicle cysts, luteinized cyst, ovarian parasitic granulomatous inflammation, dysgerminoma, leiomyoma, fibroleiomyoma and chronic fibrino-suppurative inflammation of the broad ligament. All lesions described represented first reports for L. obscurus, and the diagnosis of dysgerminoma was the first in a cetacean. It is also the first time that trematode eggs have been reported in the ovaries of cetaceans and that a vaginal calculus has been encountered in a sexually immature cetacean. The finding of struvite as a major component in two vaginal calculi suggested an infectious aetiology. Of 11 mature females with ovarian tumour or cysts or uterine tumours, only one (9.1%) was pregnant, i.esignificantly less than the expected pregnancy rate (53.3% in a random sample of Peruvian dusky dolphins). Several females with ovarian or uterine lesions and males with aberrant testes were large animals. It is possible that some of these lesions were associated with normal senescence of the reproductive system.

[Morphological and functional pelvic floor disorders from the gynecological viewpoint]

PURPOSE

The following article is designed to describe the diagnostics and therapy of morphological and functional defects in the female pelvic floor from a gynaecological point of view. Assessment of the relevance of imaging techniques is of particular importance.

MATERIAL AND METHODS

The main diagnoses are: in the anterior compartment of the pelvic floor, urethro- cystocele; in the middle compartment, uterine descent/prolapse or enterocele; and in the posterior compartment, rectocele. They are clinically examined by means of a standardised gynaecological examination and classified according to recommendations from the International Continence Society (ICS) in order to obtain internationally comparable results. Comparison with the usual imaging procedures (introitus- and perineal sonography, colpocystorectography/defaecography and functional MRI of the pelvic floor) are described and critically discussed. The most important functions affected are storage and evacuation of the bladder and rectum. They are clinically examined by means of stress test and padweigh test and technically examined using urodynamics, sphincter-rectum manometry and EMG. Imaging procedures play a very important role here also.

RESULTS

Comparison of clinical and imaging procedures shows that the two methods are at present limited in comparability, mainly because different points of reference are used to quantify results. The line of the hymen is a good point of reference in grading descent and prolapse. During the gynaecological examination, the three compartments can readily be assessed separately by use of split gynaecological specula. This is presently practically impossible using imaging procedures. The pubococcygeal line is generally used to describe findings.

DISCUSSION

Scientific progress can only be expected if and when these problems are studied as a whole. Imaging procedures have securely established themselves in the diagnostic repertoire, but do not as yet influence therapy decisions. The indication and choice of operation depend on the severity of the patient's symptoms the clinical findings and the results of urodynamic investigations. Dynamic CTG is presently the most reliable method of showing all three compartments at rest and during function. It has largely replaced colpocystorectography. Sonography is found to be varied in ist results at the moment.

Electron microscopy in pathology articles: a retrospective appraisal

Electron microscopy (EM) is a valuable standard tool in basic research and teaching. However, its use in diagnosis is limited, either for strategic reasons or budgetary constraints. This means that its many potential applications are more often neglected, either as an ancillary tool, quality control method, or gold standard, to complement, support, or confirm results of pathological studies. To evaluate the use of EM in this setting, the authors analyzed all articles (n = 2,531) in the three top indexed diagnostic pathology journals for a period of 60 months from July 1993 to June 1998. A total of 448 articles in which the use of EM was indicated, according to standard surgical pathology textbooks, were selected. Both the actual and the potential EM content of each article were scored, as follows: zero, illustrative, supportive, gold standard (for confirmation of research results), extensive, and predominant. Of the total number of articles in which EM was indicated, 77% made use of the technique. EM support was lacking most frequently in articles on serosal neoplasms and on new diagnostic strategies (p < .00005). There was no definite trend toward an increase or decrease in the use of EM during the period analyzed. The authors conclude that EM is used in most reports on diagnostic pathology, when it is indicated. However, a small but non-negligible percentage of articles (23%) could benefit from including EM as an ancillary, control, or gold standard method to complement, support, or confirm their results.

Dusting off old books: comments on classic gynecologic pathology books of yesteryear

Selected outstanding books from the older literature on gynecological pathology are reviewed with emphasis on drawing attention to the abundant helpful information and outstanding illustrations that are worthy of review by present-day pathologists. The first three works are Cancer of the Uterus, Myomata of the Uterus, and Adenomyoma of the Uterus by Thomas S. Cullen. The senior author of the second book is Howard A. Kelly even though he did not have any role in the preparation of the text; he was given senior authorship by Dr. Cullen as a token of appreciation to his mentor. The next book, Fibroids and Allied Tumors by Cuthbert Lockyer, is particularly noteworthy for the quality of the numerous color illustrations. The final book on the uterus is The Cervix Uteri and Its Diseases by C. Frederic Fluhmann. It provides detailed coverage of the normal and pathologic aspects of the cervix, including the endocervical clefts (glands) and their abnormalities. The next three books are on the ovary: Ovarian Tumors by Samuel H. Geist, Atlas of Ovarian Tumors by Gemma Barzilai, and Endocrine Pathology of the Ovary by John McLean Morris and Robert E. Scully. The first is notable for the quality of the coverage of clinical and gross aspects of ovarian tumors and the second for the quality of the description of the microscopic features. The third book expanded the range of functioning ovarian tumors by showing that this could be a feature of tumors not usually considered hormonally active and also discussed in detail the endocrine function of non-neoplastic lesions. The final two books cover general gynecological pathology: Manual of Obstetrical and Gynaecological Pathology by John H. Teacher and Gynecological and Obstetrical Pathology by Emil Novak. Both have particularly outstanding coverage of normal histology and non-neoplastic lesions.

Female genital schistosomiasis

Schistosoma haemtobium infection in travelers from endemic areas is usually asymptomatic, or presents with hematuria. Uncommon manifestations include neurological syndromes, genital dysaesthesias and watery or blood stained semen. This organism also causes disease within all structures of the female genital tract because of communications between pelvic venous complexes, and can occur long after return home. Schistosomiasis may not be suspected, resulting in delays in diagnosis and treatment. We present two cases which illustrate the diverse nature of this condition.

Genetics of the female reproductive ducts

Familial aggregates of the most common disorders of müllerian differentiation in females-Müllerian aplasia, incomplete Müllerian fusion-are best explained on the basis of polygenic/multifactorial inheritance. No information exists on the number and chromosomal location of responsible genes. Single mutant genes (Mendelian) are responsible for the McKusick-Kaufman syndrome (MKS) and the hand-foot-genital syndrome. The molecular basis for the latter condition involves HOXA13, but the molecular basis of MKS and other disorders of the female reproductive ducts is unknown. Vaginal atresia, Müllerian aplasia, and incomplete Müllerian fusion are not infrequently observed in malformation syndromes.

French gynecologic cytology

Diagnostic schema may be developed on a national or global level, but may be varied depending on the local conditions. In this article, the differences between French and North American gynecologic cytology are discussed. This article emphasizes the training, diagnostic, technologic, and regulatory differences that exist in France. By studying such differences, local practices can learn potential benefits and why their currently used systems may be optimal.

The intercellular adhesion molecule type-1 is required for rapid activation of T helper type 1 lymphocytes that control early acute phase of genital chlamydial infection in mice

Recent studies in animal models of genital chlamydial disease revealed that early recruitment of dendritic cells and specific T helper type-1 (Th1) cells into the genital mucosae is crucial for reducing the severity of the acute phase of a cervico-vaginal infection and arresting ascending disease. These immune effectors are therefore important for preventing major complications of genital chlamydial infection. Other in vitro studies showed that intercellular adhesion molecule-1 (ICAM-1) plays a role in the antichlamydial action of specific CD4+ and CD8+ T cells. In the present study, we investigated the clinicopathological consequences of ICAM-1 deficiency during chlamydial genital infection in ICAM-1 knockout (ICAM-1KO) mice, and analysed the cellular and molecular immunological bases for any observed pathology or complication. Following a primary genital infection of female ICAM-l-/- and ICAM-1+/+ mice, the intensity of the disease during the first 3 weeks (as assessed by shedding of chlamydiae in the genital tract) was significantly greater in ICAM-1KO mice than in ICAM-1+/+ mice (P < 0.0001), although both ICAM-l-/- and ICAM-1+/+ mice subsequently cleared the primary infection. There was greater ascending disease during the initial stage of the infection, and a higher incidence of tubal disease (hydrosalpinx formation) after multiple infections in ICAM-l-/- mice. Analysis of the cellular and molecular bases for the increased acute and ascending disease in ICAM-l-/- mice revealed that the high affinity of ICAM-1 for leucocyte function antigen type-1 is a property that promotes rapid activation of specific Th1 cells, as well as their early recruitment into the genital mucosa. Moreover, ICAM-1 was more important for naive T-cell activation than primed Th1 cells, although its absence delayed or suppressed immune T-cell activation by at least 50%. Taken together, these results indicated that ICAM-1 is crucial for rapid T-cell activation, early recruitment and control of genitally acquired Chlamydia trachomatis.

Increased telomerase activity and decreased telomere length in genital condylomata acuminata

Our objective was to find a possible correlation between telomerase activity, mean telomere length and human papillomavirus (HPV) presence and type in genital condylomata acuminata. Fifteen biopsies from women with genital condylomata acuminata and nine control tissue samples were tested for telomerase activity, mean telomere length, and HPV presence and type. All condylomata exhibited telomerase activity, compared to 78% of the control samples. The mean telomere length of condylomata was significantly (P<0.002) shorter compared to telomere length in control tissue samples. All condylomata lesions were infected with HPV types 6/11, and more than half had additional infection with HPV 16/18. Mixed HPV 6/11 with 16/18 infection correlated with shorter telomeres than presence of HPV 6/11 alone in the lesions (4.68 +/- 0.44 kb vs 4.97 +/- 0.57 kb). None of the control tissue samples showed presence of HPV DNA. Telomerase activity may be a marker of proliferation rather than malignancy, whereas the mean telomere length could better serve as a marker for the progression of HPV lesions toward malignancy.

Peritoneal washing cytology is unnecessary in gynecologic surgery for benign diseases

BACKGROUND

The presence of tumor cells in peritoneal washing cytology specimens taken during surgery affects the staging of many gynecologic malignancies. Peritoneal washings are often collected routinely, even in cases of presumed benign disease. This study was designed to address whether evaluation of these specimens is justified.

METHODS

We reviewed diagnostic reports from all peritoneal washings and the corresponding surgical pathology specimens from patients undergoing gynecologic surgery during a 1-year period in one institution and a 20-month period in the other. Cases were divided into benign and malignant categories based on the surgical pathology diagnosis.

RESULTS

Three hundred forty-six patients had peritoneal washings collected during the study period. The proportion of cases with malignancy was 30% in one institution and 49% in the other. Of these, 119 had an endometrial or ovarian malignancy, including 16 ovarian tumors of low malignant potential. Malignant cells were detected in 19 cases. In 10 of these 19, grossly apparent peritoneal tumor implants were present at the time of surgery. The remaining 227 were found to have benign disease, and the peritoneal washing cytology diagnosis was negative in all cases. Potential savings of $13,000 to $17,000 based on current insurance reimbursement could have been realized for these 227 patients without compromising patient care.

CONCLUSIONS

These data suggest that peritoneal washing cytology specimens collected at the time of gynecologic surgery for presumed benign disease can be held and processed later if an unsuspected malignancy is discovered. This practice can result in cost savings without compromising patient care. Cancer (Cancer Cytopathol)

[Detection of human papillomavirus DNA by molecular hybridization in tube: interest in cervical neoplasia]

The presence of human papillomavirus (HPV) DNA in 79 cervical specimens obtained from 70 patients was studied by using a molecular hybridization technique performed in tube. The results were compared to those of the cytological and histological studies. The molecular hybridization technique in tube (Hybrid Capture I) detects two groups of HPV types. One group is highly associated with the development of cancer (types 16, 18, 31, 33, 35, 45, 51, 52, 56) whereas the second group (types 6, 11, 42, 43, 44) is not. Among 42 patients with cervical lesions before any treatment, high risk DNA of HPV was found in 50% of those with low grade cytology and 90% with high grade cytology. In total, 32 out of the 42 patients (76%) who presented histological lesions, were actually infected by HPV. Samples were obtained before and after treatment from 9 patients. Seven out of 9 presented high grade cervical intraepithelial neoplasia (CIN) and 2 other patients had low grade CIN. HPV DNA was not detected in any of the patients after treatment. Detection of HPV DNA by molecular hybridization in tube is simple, sensitive, standardized, inexpensive and is well adapted to screening programs. It can be used in complement of the cytological diagnosis, in the surveillance of equivocal cytological abnormalities, and in the follow-up of treated patients.

Atlas of obstetric and gynecologic emergencies

Obstetric emergencies are rarely photographed. They often occur late at night when all personnel are involved in life-saving maneuvers, precluding the opportunity to record graphic representation of the pathology. Included in this atlas are several such cases.

Colposcopic diagnosis: clinical aspects and experiences

Colposcopy can be applied as an integral part of every gynecologic examination in concert with cytology; to identify and localize lesions suspected on the basis of abnormal cytology findings; and to clarify the nature of clinically suspicious lesions. This implies using colposcopy to clarify the nature of cervical changes seen with the naked eye. This practice is superior to colposcopy which is restricted to evaluating abnormal smears because it can pick up some lesions missed by cytology. But it is not as effective as routine colposcopy because it can miss lesions not picked up by gross inspection of the cervix and because there is no opportunity to inspect the lower tract of the cervical canal. Considering that only 15-20% of lesions are purely endocervical, not too much time is wasted by examining these cases. If colposcopy is limited to evaluating grossly suspicious lesions, then its role is merely to avoid unnecessary biopsies.

Phase 1 trial of nonoxynol-9 film among sex workers in South Africa

OBJECTIVES

To assess the acceptability and safety of a vaginal nonoxynol-9 film in a group of sex workers at a truck stop in South Africa.

DESIGN

A randomized double-blinded crossover trial was conducted between April 1995 and July 1995.

INTERVENTION

Seventy-two mg nonoxynol-9 film and an identical glycerine placebo film.

METHODS

Following informed consent, each study participant was randomly assigned the designated pre-coded film for 1 month. The second month was a film-free washout period and the participants used the alternate film in the third month. Besides measuring behavioural and clinical outcomes, colposcopy examination for genital lesions, serology and microbiology investigations for sexually transmitted diseases and semi-quantitative PCR for vaginal HIV load estimates were performed.

RESULTS

Twenty women participated in the study. The women reported, on average, 19 sexual encounters per week. Vaginal intercourse was protected 25% of the time by condoms. On average, 11 vaginal films, either nonoxynol-9 or placebos were inserted per week. There were no statistically significant differences between the two treatment groups for genital lesions (P = 0.29), reported side effects (P = 0.73), and viral load (P = 0.9). However, the proportions of clinically detected genital lesions (six out of eight versus two out of eight) and self-reported side-effects (five out of eight versus three out of eight) were higher in the nonoxynol-9 group when compared with the placebo group. Incident sexually transmitted diseases occurred more frequently in the placebo group. An increased viral load was associated with the development of a genital lesion (relative risk, 6.0; 95% confidence interval, 0.81-44.4).

CONCLUSIONS

The 72 mg film formulation of nonoxynol-9 was an acceptable product for use in this population of sex workers. Although no statistically significant differences in adverse outcomes were detected, clinically there appeared to be an increase in minor lesions and self-reported side-effects with nonoxynol-9 and less protection against sexually transmitted diseases with the placebo. Furthermore, HIV shedding was correlated with the presence of incident vaginal or cervical lesions. This brings into question the potential narrow margin of safety for this product; additional Phase 2 studies are therefore required.

Gynecologic cytology turnaround time. A College of American Pathologists Q-Probes Study of 371 laboratories

OBJECTIVES

To determine the turnaround time for gynecologic cytology in a large sample of laboratories and to identify laboratory and specimen characteristics associated with better and worse performance.

DESIGN AND SETTING

Prospective evaluation of gynecologic cytology turnaround times in 371 laboratories.

MAIN OUTCOME MEASURE

Gynecologic cytology case turnaround time.

RESULTS

Three hundred seventy-one laboratories submitted information regarding laboratory characteristics and processes, and turnaround times of 66 042 gynecologic cytology cases. Half of the participating laboratories had mean turnaround times of 6 calendar days or less and were able to complete 90% of their cases within 8 calendar days. Ten percent of participants had mean turnaround times greater than 13 days and required 19 or more days to report 90% of their cases. Longer turnaround times were associated with the use of reference laboratories for all or part of the evaluation; contacting the physician's office for additional information; using cytotechnology students, residents, or fellows in the evaluation; and providing service on the weekend.

CONCLUSION

Practice patterns contribute to the long turnaround times for gynecologic cytology found in some laboratories and may be improved by local site-specific process analysis.

[The state of the lymphatic system in inflammation of the internal sexual organs]

In conditions of experimental inflammation of internal sexual organs in female rats fast and adequate reorganization of its lymphatic bed was found. In the nidus of inflammation sufficient drainage of tissues was retained. Loose and widened sinuses of ileal lymph nodes provided sufficient intranodal lymphodynamics. Formation of additional barrier composed of lymphoid cells was detected in paravaginal fat. Reduction of the speed of lymph flow within lymphangions promoted adequate conveyance of toxic lymph to nodes and its further processing. Mobilization of all links of lymphatic barrier resulted in its maximum activation and self recovery by d 14.