Uterine rupture after hysteroscopic metroplasty and labor induction. A case report

BACKGROUND

Hysteroscopic metroplasty has become the method of choice for the treatment of uterine septa. Uterine perforation has been reported in about 1% of surgical hysteroscopic procedures. Ultrasound allows the detection of uterine lesions.

CASE

A woman who conceived after complicated hysteroscopic metroplasty underwent emergency cesarean section because of uterine rupture during labor induced with prostaglandins (PGE2). An ultrasound scan performed two years later revealed a uterine lesion that corresponded to the myometrial tear reported at cesarean section.

CONCLUSION

Complicated hysteroscopic metroplasty may promote acute uterine rupture during pregnancy and labor. Ultrasound is a useful tool for the detection of uterine lesions. If adequately considered, it might have allowed more rational management of labor in this case. PGE2 should never be used for induction of labor after complicated metroplasty.

Foscarnet-induced crystalline glomerulonephritis with nephrotic syndrome and acute renal failure after kidney transplantation

Foscarnet nephrotoxicity has been reported to be associated with acute tubulointerstitial nephritis. Crystals in glomerular capillary lumens have also been observed in patients with acquired immunodeficiency syndrome who were treated with foscarnet for cytomegalovirus disease. We describe a kidney transplant recipient who developed a nephrotic syndrome with microscopic hematuria and nonoliguric acute renal failure within 15 days after starting foscarnet therapy for cytomegalovirus infection. A kidney biopsy specimen showed the presence of crystals in all glomeruli and in proximal tubules. Fourier transform infrared microscopy analysis demonstrated that crystals were made from several forms of foscarnet salts: mixed calcium and sodium salts, and unchanged trisodium foscarnet salts. Renal function and proteinuria spontaneously improved, and a second transplant biopsy performed 8 months after the first one revealed fibrotic organization of half of the glomeruli and of interstitial tissue, and crystal vanishing. We were thus able to provide proof of the possible precipitation of foscarnet in a transplanted kidney.

Conservative treatment followed by chemotherapy with doxorubicin and ifosfamide for cervical sarcoma botryoides in young females

Sarcoma botryoides of the cervix is an extremely rare tumour and seems to be associated with a better prognosis than its vaginal counterpart. Recent studies have suggested that it is possible to limit surgery to local excision in stage I cases. We report three cases of young subjects treated successfully with polypectomy or diathermy loop excision followed by adjuvant chemotherapy. One patient had a local recurrence which was treated with further local excision. All subjects remain alive without evidence of recurrence and with normal menstrual function 36, 38 and 38 months following initial diagnosis. A conservative surgical approach to early cervical sarcoma botryoides is possible. The efficacy of adjuvant chemotherapy and the regimen of choice still need to be investigated.

Irreversible glomerular lesions induced by crystal precipitation in a renal transplant after foscarnet therapy for cytomegalovirus infection

AIMS

Foscarnet is an antiviral agent used to treat cytomegalovirus infection in AIDS patients and in transplant recipients. In most cases, foscarnet induces reversible tubulo-interstitial lesions which can be avoided by correct hydration. We report the first case of crystal foscarnet precipitation within glomerular capillaries in a renal transplant.

METHODS AND RESULTS

The recipient, a 49-year-old man, developed a nephrotic syndrome with haematuria and an acute renal failure after foscarnet therapy for cytomegalovirus (CMV) infection. The polarization examination of the first graft biopsy revealed the presence of birefringent crystals within glomeruli and tubules. Infrared analysis attested to the presence of trisodium foscarnet salts and mixed sodium calcium salts coloured by Von Kossa's reaction. A second biopsy showed glomerular sclerosis, interstitial fibrosis, tubular atrophy and crystal vanishing. Polymerase chain reaction (PCR) in situ applied to this biopsy confirmed the diagnosis of cytomegalovirus infection.

CONCLUSIONS

These adverse effects might be the result of a toxic synergy between foscarnet and other drugs. In cases with crystalline precipitation, graft biopsy remains the best mean of diagnosis and follow-up of glomerular damage.

Mesothelial cells induce the motility of human ovarian carcinoma cells

The dissemination of ovarian carcinoma cells within the abdominal cavity involves interaction of tumor cells with the peritoneal mesothelium. The aim of our study was to investigate whether mesothelial cells might directly affect the spreading of this tumor by inducing motility and invasiveness of human ovarian carcinoma cells. Serum-free supernatants of cultured human mesothelial cells [conditioned medium (CM)] induced chemotaxis and invasiveness of the human ovarian carcinoma cell lines SK-OV-3, OVCAR-5 and A2780 in a Boyden chamber. Checkerboard analysis indicated that the stimulated motility was prevalently directional. Most of the chemotactic activity was retained by a heparin affinity column, indicating that the motility factor(s) is a heparin-binding protein. Using different monoclonal antibodies (MAbs) directed against chemotactic factors that are secreted by mesothelial cells, we found that chemotaxis was partially prevented (64.8% inhibition) by antibodies against fibronectin (FN). CM also induced haptotactic migration of ovarian carcinoma cells, and anti-FN antibodies significantly inhibited haptotaxis. The presence of FN in the CM was confirmed by Western blot analysis. Our findings suggest that mesothelium plays an active role in inducing the intraperitoneal spread of ovarian carcinoma cells, and point to FN as being one of the main mediators of mesothelium-induced ovarian carcinoma cell motility.

The accuracy of staging: an important prognostic determinator in stage I ovarian carcinoma. A multivariate analysis

BACKGROUND

Several prognostic factors for stage I ovarian carcinoma have been analyzed. Some of them are biological and clinical in nature, but others such as the thoroughness of the staging procedure, the extent of the surgery and the philosophy of treatment, are defined by the human element.

PATIENTS AND METHODS

We reviewed the records of 351 patients with Stage I ovarian cancer who had been treated from 1981 to 1991. For all patients the following information was available: age, size of the tumor, FIGO sub-stage, tumor grade, histologic type, rupture of the tumor, cytology, extent of the staging and of the surgery (hysterectomy and bilateral salpingo-oophorectomy vs. fertility-conserving surgery) and use of adjuvant treatments. The thoroughness of the staging was defined as: optimal staging: total abdominal hysterectomy and bilateral salpingo-oophorectomy or fertility-conserving surgery, peritoneal cytology or washing, omentectomy, multiple peritoneal biopsies, sampling of the retroperitoneal nodes or formal lymphadenectomy, peritoneal staging: all the criteria described above were met with the exception of retroperitoneal sampling, incomplete staging: lack of any of the previously-cited criteria.

RESULTS

An optimal staging was performed in 100 patients, a peritoneal staging in 107 and an incomplete staging in 144. Radical surgery was performed in 295 women and fertility-conserving surgery in 56. With a median follow-up of 108 months (range 14-184) 64 patients had recurrence of the tumor. Fifty-three died of the disease, two are currently alive with disease and nine were salvaged by surgery and/or chemotherapy. In a multivariate analysis only the tumor grade and the type of staging were significant independent prognostic factors for both disease-free and overall survival.

CONCLUSIONS

As described by other authors, we confirm that tumor grade is the single most important biological prognostic factor in early ovarian carcinoma. The thoroughness of the staging impacts significantly on survival, particularly in poorly differentiated carcinomas. Fertility-sparing surgery is not associated with a worse outcome than standard radical surgery.

Neoadjuvant chemotherapy with cisplatin, ifosfamide and paclitaxel for locally advanced squamous-cell cervical cancer

BACKGROUND

Neoadjuvant chemotherapy is increasingly being used for the treatment of bulky and locally-advanced cervical cancer. Cisplatin and ifosfamide are known to be effective in cervical cancer, while paclitaxel is one of the promising new drugs for the treatment of this neoplasm.

OBJECTIVE

To assess the toxic effects and antitumor activity of a multidrug neoadjuvant regimen consisting of cisplatin, ifosfamide, and paclitaxel in bulky and locally advanced cervical cancer.

PATIENTS AND METHODS

Thirty-eight patients with pathology-confirmed squamous-cell cervical cancer (27 IB2-IIA, two IIB, eight IIIB, one IVA) were prospectively enrolled in the study. Their treatment consisted of paclitaxel 175 mg/m2 given over three hours on day 1, cisplatin 50 mg/m2 (75 mg/m2 in 10 patients), ifosfamide 5 g/m2 in a 24-hour continuous infusion and mesna 5 g/m2 in a 24-hour continuous infusion on day 2, and mesna 3 g/m2 in a 24-hour continuous infusion on day 3. The course was repeated every three weeks for three courses and all of the patients, except those with disease progression or who were inoperable, were scheduled for radical hysterectomy and pelvic lymphadenectomy.

RESULTS

All patients are evaluable for response. Eleven achieved clinical complete responses, 21 had partial responses, five had stable disease and one had progression of disease. Of 34 patients who underwent surgery, six (16%) had pathology-documented complete responses, seven (18%) had partial responses with only microscopic residual disease in the cervix, 19 had sub-optimal partial responses, and two had stable disease, for an overall response rate of 84% (95% confidence intervals (CI): 68.7%-94%). Grade 3-4 neutropenia was recorded for 27 (71%) patients, grade 3-4 thrombocytopenia for four (10.5%), and grade 2 peripheral neuropathy for two (2.5%). At a median follow-up of 16 months (range 7-22), 29 (76%) women are alive without recurrence, seven are alive with persistent/recurrent disease and two have died of their disease.

CONCLUSIONS

According to pathology examination, this regimen yields a 34% complete and optimal partial response rate with acceptable toxicity, and it should be prospectively compared to other regimens.

Complete remission of brain metastases from ovarian carcinoma with carboplatin

Central nervous system involvement by epithelial ovarian carcinoma is rare. We report the case of a 49 year old woman with stage IV serous carcinoma of the ovary who developed multiple cerebral and cerebellar metastases 7 months after achieving complete response to platin-based chemotherapy. Eight courses of carboplatin (400 mg/m2) were administered and after the second cycle complete remission of the brain deposits occured. The treatment afforded rapid subjective and objective relief and was associated with a good quality of life. Abdominal recurrent disease was diagnosed 22 months after treatment for brain involvement. Paltin-based chemotherapy was reinstated, but the patient died from progressive adbominal disease without any sign of cerebral involvement and any neurological symptomatology. Carboplatin should be considered for the treatment of ovarian carcinoma metastatic to the brain.

Ureteral endometriosis diagnosed at ureteroscopy

BACKGROUND

Intrinsic ureteral endometriosis is rare. Early detection and treatment is extremely important to preserve renal function.

CASE

A 37-year-old woman with right flank pain was diagnosed with a polypoid lesion at excretory urogram. The polyp was removed under ureteroscopy and was found to be endometriosis. Subsequent exploratory laparotomy and ureterolysis failed to document other foci of endometriosis. Resection of the ureter was not needed. She received medroxyprogesterone for 6 months, and a ureteral stent was left in place for 3 months postoperatively. Excretory urogram showed no obstruction 6 months postoperatively.

CONCLUSION

This appears to be the first reported case of ureteral endometriosis documented initially at ureteroscopy. Prompt treatment may relieve symptoms and preserve renal function. Resection of the ureter may be avoided in some patients.

Conservative surgery for stage I ovarian carcinoma in women of childbearing age

OBJECTIVE

To assess the results of a policy of tailored conservative surgical management for young women with stage I ovarian carcinomas.

DESIGN

Retrospective study.

PARTICIPANTS

Ninety-nine women aged 40 years or younger who underwent either primary surgery in our department or were referred after primary surgery performed elsewhere.

METHODS

Of the 99 women in our study, 56 underwent fertility-sparing surgery and 43 more radical surgery. Minimal requirements for conservative management were adequate staging and complete information about the therapeutic options. Factors important in the choice of the treatment were, age, wish to preserve fertility, histologic type and grade, and the stage of the tumour.

RESULTS

Conservative treatment was conducted in 84% of nulliparous and in 33% of parous women; 62% of grade 1 tumours, 48% of grade 2, and 50% of grade 3 were treated conservatively. With a median follow up of seven years, we observed five recurrences (9%) of carcinoma in women treated conservatively and five (12%) in those treated more radically. Two women (one in each treatment arm) were saved after recurrence. Two recurrences after conservative surgery involved the residual ovary (3.6%). Two women developed borderline tumour in the contralateral ovary and both were treated by surgery.

CONCLUSION

After adequate staging and accurate information is given to the patient, conservative treatment may be safe in some women with early ovarian cancer. The risk of recurrence in the contralateral ovary is low. Conservative surgery may be also considered in some Stage I grade 3 tumours and in some women with stage JC tumours.

Transvaginal ultrasonographic characterization of ovarian masses: comparison of five scoring systems in a multicenter study

The aim of this work was to test and compare the accuracy of five different morphological scoring systems to identify malignant ovarian masses in a prospective multicenter study. Four of the systems had previously been reported by Granberg, Sassone, De Priest and Lerner and the fifth is newly developed. A total of 330 ovarian neoplasms were collected in three different centers, which adopted the same diagnostic procedures. Of these, 261 masses were benign (mean diameter 50 +/- 26 mm) and 69 were malignant (mean diameter 69 +/- 33 mm) (prevalence 21%). The area under the receiver operating characteristic (ROC) curve for the multicenter score was 0.84. This was significantly better than the areas of the other four scores which ranged from 0.72 to 0.75. The cut-off levels derived from the five ROC curves achieved a sensitivity that ranged from 74% (Sassone score) to 88% (De Priest score > or = 5), and a specificity from 40% (De Priest) to 67% (multicenter); the highest positive predictive value was 41% (multicenter). With a cut-off level of 9, the accuracy of the multicenter score was significantly better than the scores of Granberg and De Priest (McNemar's test p < 0.0001). Similar results were obtained in 207 ovarian masses of < or = 5 cm in mean diameter, and when 19 borderline and 11 stage 1 cancers only were considered. For the clinical purposes of a screening test we also checked a possible cut-off level of > or = 8, which increased the sensitivity to 93% with a drop of specificity to 56%. With the use of the same criteria for the scores of the different authors, the following values were obtained for sensitivity: 96%, 81%, 93% and 90%; and for specificity: 23%, 56%, 28% and 49%. The multicenter score performed well at distinguishing malignant from benign lesions, and was better than the other four traditional scores, for both large and small masses. This was mainly due to the introduction of two criteria that allowed correction for typical dermoids and endohemorrhagic corpora lutea. A completely reliable differentiation of benign from malignant masses cannot be obtained by sonographic imaging alone.

Treatment of fallopian tube carcinoma with cyclophosphamide, adriamycin, and cisplatin

Primary carcinoma of the fallopian tube is uncommon; optimal primary treatment is still not well defined, and little information is available about the efficacy of cisplatin-based combination chemotherapy. Thirty-eight patients with fallopian tube carcinoma were treated with cyclophosphamide (500 mg/m2), Adriamycin (50 mg/m2), and cisplatin (50 mg/m2) (CAP). Thirty-two patients received the combination chemotherapy as first-line treatment after cytoreductive surgery, whereas six subjects were treated for recurrent disease. The patients received a median of six cycles of therapy (range, four to nine). At the initiation of chemotherapy, 24 patients had measurable lesions. In this group of patients, 15 had a clinical complete response (CR), four had a partial response (PR), three had stable disease (SD), and two had progressive disease (PD) after chemotherapy. The overall clinical response rate (CR + PR) was 80%. Ten of the 14 CR patients who were submitted to second-look operation (SLO) were found free of disease, in pathologic complete response (pCR). Three pCR patients relapsed, and two of them died despite second-line treatment. Nine patients achieving PR, SD, and PD after first-line chemotherapy were further treated (five with chemotherapy, two with radiotherapy, two with progesteron), but none responded to second-line treatment and all died (median survival, 9 months). Fourteen patients without gross residual disease after cytoreductive surgery had no measurable lesions and were not evaluable for response. Seven of them had negative SLO and remain disease free. Three patients (two stage III and one stage II) who refused SLO relapsed 14, 16, and 26 months after completion of chemotherapy. The median survival for the entire group was 38 months, and the 5-year survival rate was 35%. The toxicity of the regimen was moderate. The CAP regimen appears to be active in primary fallopian tube carcinoma and yields response rates comparable to those reported for epithelial ovarian cancer.

Intense neoadjuvant chemotherapy with cisplatin and epirubicin for advanced or bulky cervical and vaginal adenocarcinoma

Twenty-two consecutive patients with bulky or locally advanced cervical or vaginal adenocarcinoma were treated with a neoadjuvant chemotherapy regimen consisting of nine weekly courses of cisplatin (50 mg/m2) and three courses of epirubicin (70 mg/m2) at Weeks 1, 4, and 7, followed by radical hysterectomy. Salvage radiotherapy was administered to inoperable patients, whereas postoperative treatment with irradiation or further chemotherapy was given to those with detection of risk factors at surgery. Three patients (14%) did not complete the planned courses of chemotherapy (one refused after the first administration, one had severe myelotoxicity, and one had severe nephrotoxicity). Twenty-one subjects received at least four courses of treatment and were therefore evaluable for response. We observed 4 clinically complete and 10 partial responses, accounting for an objective response rate of 67%. Eighteen subjects (82%) underwent surgery without serious complications. No histopathologic complete response was observed. The response rate is in the lower range observed with other regimens for squamous cell carcinoma. Although feasible, this regimen implies a significant risk of myelotoxicity. This enhanced toxicity may be justified only if balanced by long-term survival.

Choriocarcinoma coexistent with intrauterine pregnancy: two additional cases and a review of the literature

Choriocarcinoma coexistent with normal intrauterine pregnancy is rare and poses questions about its origin. Although the development from trophoblastic remnants of previous pregnancies can not be excluded in some cases, the findings of incidental macro- and microscopic foci of choriocarcinoma in apparently normal placentas show the possible transformation of normal trophoblast into choriocarcinoma during an otherwise normal pregnancy. The diagnosis and management of choriocarcinoma coexistent with intrauterine pregnancy have changed dramatically over the decades but the survival rates are still unsatisfactory. In this review, we summarize some of the most common features of this disease.

Role of puncture and aspiration in expectant management of simple ovarian cysts: a randomised study

OBJECTIVES

To assess the potential of expectant management for simple ovarian cysts diagnosed by transabdominal or transvaginal ultrasonography. To compare the results of needle aspiration with those achieved with simple observation.

DESIGN

Randomised trial.

SETTING

Hospital department of obstetrics and gynaecology.

SUBJECTS

278 women with simple cysts randomly allocated to simple observation (143) or ultrasound guided fine needle aspiration (135) between 1990 and 1994.

MAIN OUTCOME MEASURES

Resolution of cyst or development of malignancy.

RESULTS

After six months 269 were available for follow up. The rate of resolution was 46% (59/128) with aspiration and 44.6% (63/141) with observation. Only the diameter of the cyst (P < 0.0001) was a significant independent prognostic factor for resolution in a multivariate analysis. Age and treatment had no significant effect. One woman was subsequently found to have borderline malignant changes on histopathological examination. Her cyst was detected by transabdominal ultrasonography.

CONCLUSIONS

Expectant management for up to six months does not cause risks for the patients and allows spontaneous resolution in over a third of cases, avoiding the costs and risks of unnecessary surgery. Aspiration does not provide better results than simple observation.

Flow-cytometric analysis of deoxyribonucleic acid content in advanced ovarian carcinoma: its importance in long-term survival

OBJECTIVE

Our purpose was to evaluate the importance of deoxyribonucleic acid content to long-term survival from advanced epithelial ovarian carcinoma.

STUDY DESIGN

Clinical and pathologic prognostic factors, including deoxyribonucleic acid content measured by means of flow cytometry, were analyzed for 282 patients.

RESULTS

In 80% of the patients, the deoxyribonucleic acid patterns were nondiploid. In univariate analysis stage (p < 0.0001), residual disease (p < 0.0001), deoxyribonucleic acid index (p = 0.01), and deoxyribonucleic acid ploidy (p = 0.02) significantly predicted progression-free survival. In multivariate analysis stage (p < 0.001), residual tumor (p = 0.001), deoxyribonucleic acid ploidy (p = 0.02), and deoxyribonucleic acid index (p = 0.02) retained independent prognostic value. Residual disease and deoxyribonucleic acid content retained independent prognostic value for stage III tumors but not for stage IV tumors.

CONCLUSION

Deoxyribonucleic acid analysis with flow cytometry provides prognostic information about long-term progression-free survival from advanced ovarian carcinoma and should be considered in the stratification processes of patients in future clinical trials. This prognostic information appears to be inversely related to tumor burden.

Phase II study of paclitaxel as salvage treatment in advanced endometrial cancer

OBJECTIVE

To evaluate the antitumour activity of paclitaxel in patients with endometrial cancer pretreated with cisplatin, doxorubicin and cyclophosphamide (PAC).

MATERIALS AND METHODS

Eligible patients had complete initial surgery, expected survival > or = 3 months, performance status < or = 1, measurable or evaluable disease. Paclitaxel was given over three hours at the dose of 175 mg/m2, repeated every 3 weeks. Tumour response was first evaluated after 3 cycles. A maximum of 10 cycles was given in responders.

RESULTS

19 patients entered the study and a total of 105 cycles were administered. Complete and partial responses were achieved in 2 and 5 patients, respectively, for an overall response rate of 37% (95% CI: 16%-62%). The response rate in patients refractory to platinum was 22%. One patient is alive without evidence of disease 16 months after the start of treatment. The most common side effects were mild to moderate myalgia and peripheral neuropathy, which occurred in 31% and 47% of patients, respectively. In only 1 patient treatment had to be discontinued because of severe myalgia.

CONCLUSION

Paclitaxel is active in patients with endometrial cancer pretreated with PAC. Further studies with paclitaxel incorporated in the initial treatment for advanced disease are warranted.

DNA index by flow cytometric analysis: an additional prognostic factor in advanced ovarian carcinoma without residual disease after primary operation

Patients with no macroscopic residual disease after primary cytoreductive operation are considered to have the most favorable prognosis among subjects with advanced ovarian carcinoma. Nevertheless, approximately half of these patients eventually die of recurrent disease. The identification of more cogent prognostic factors within this subcategory of patients might allow for improved design of postoperative adjuvant treatment. The prognostic significance of several clinical and pathologic factors, including DNA content, was evaluated in 27 patients afforded complete cytoreduction at primary operation who were participants in prospective clinical trials of adjuvant chemotherapy for advanced ovarian carcinoma. After a median follow-up of 120 months, 14 patients were alive without evidence of disease and 13 had died of progressive disease. DNA index provided statistically significant prognostic information on the outcome (P = 0.02). Eleven of the 16 patients with a DNA index more than 1.3 died of tumor (8-year survival, 35%), whereas only 2 of the 11 with a DNA index less than 1.3 died (8-year survival, 79%). In addition, menopausal status was of borderline significance for predicting survival (P = 0.04). The prognostic impact of the DNA index became progressively more evident with longer follow-up. Confirmation of this observation in larger sample populations may provide useful information for designing future clinical trials for this prognostically favorable subset of patients who have optimal reduction with advanced ovarian epithelial carcinoma.

Concurrent preoperative chemotherapy with 5-fluorouracil and mitomycin C and radiotherapy (FUMIR) followed by limited surgery in locally advanced and recurrent vulvar carcinoma

To prospectively evaluate the feasibility and efficacy of neoadjuvant chemoradiotherapy locally advanced or recurrent vulvar carcinoma, 58 patients referring for primary (41) or recurrent (17) disease received preoperative external radiotherapy to a dose of 54 Gy, divided into two courses with an interval of 2 weeks. 5-Fluorouracil (750 mg/m2 daily for 5 days) and mitomycin-C (15 mg/m2 single bolus) were given at the start of each cycle. Wide local excision and inguinal lymphadenectomy were planned after treatment. Eighty-nine percent of patients completed the chemoradiotherapeutic treatment, whereas 72% underwent surgery. Objective responses were observed in 80% of vulvar diseases and in 79% of groin metastases. Pathologic complete response of both the vulvar and inguinal disease was confirmed in 13 patients (31%). Early severe toxicity was recorded in 3 patients and severe worsening of performance status in 3. Three deaths occurred shortly after treatment and at least one is directly related to toxic effects. This treatment allows good control of locally advanced and recurrent vulvar cancer with acceptable side effects. Further follow-up is required to determine the long-term outcome and the effectiveness of the surgical procedure.

Safety of transvaginal fine needle puncture of gynecologic masses: a report after 500 consecutive procedures

Transvaginal sonographically guided puncture may be used for diagnostic and therapeutic purpose in general gynecology and in oncology. To define the complication rate of this technique, 500 consecutive procedures were reviewed; 289 procedures were on cystic masses, 146 on solid tumors, 34 on mixed tumors, and 31 on other lesions. No life-threatening complications occurred. Early mild and self-limited complications developed in eight procedures (1.6%). Short-term complications occurred in four cases (0.8%; two infections, one pelvic pain, one hemorrhage); two of these required surgery. Transvaginal sonographically guided puncture is safe and does not entail a higher risk of infection than transabdominal punctures.

Brain metastases from endometrial carcinoma

Central nervous system (CNS) involvement by endometrial carcinoma is uncommon. Among 1069 patients registered for endometrial carcinoma at our institution between 1982 and 1994, 10 (0,9%) developed brain metastases. Median age at the time of CNS metastasis diagnosis was 59 years. Median interval between diagnosis of endometrial cancer and documentation of brain involvement was 26 months. Clinical manifestation of brain metastasis included headache (80%), motor weakness (50%), seizures (20%), confusion (10%), balance (10%), and visual disturbances (10%). All lesions (4 multiple, 6 single) were contrast enhancing on computed tomography (CT) scans, and were located in the cerebrum in seven cases, in the cerebellum in one case, and in both in two cases. The CNS was the only site of detectable disease in six patients with recurrent disease. Nine patients died and one is alive with disease 3 months after surgical resection of a single cerebral deposit. Median survival from diagnosis of brain metastases for the entire series was 1 month (range 1-83). Six patients receiving only steroids died within 1 month from the diagnosis. One patient received radiotherapy (survival, 3 months) and two underwent surgical resection of solitary metastasis followed by radiotherapy (survival = 28 and 83 months). Prognosis of patients with CNS metastases from endometrial carcinoma appears poor; however, in a selected group of patients early diagnosis followed by multimodal treatment may result in a palliation of the disease.

The Burch colposuspension for women with and without detrusor overactivity

OBJECTIVE

To compare the results of the Burch colposuspension in women with stress urinary incontinence and detrusor overactivity with those obtained in women with stress incontinence and stable bladders. Additionally, to analyse the value of two detrusor instability indexes and of standard cystometric parameters in predicting the surgical outcome.

DESIGN

Retrospective cohort study.

SETTING

Secondary referral centre Urodynamics Unit, San Gerardo Hospital, Monza.

SAMPLE

Forty-four women with detrusor overactivity (21 with low compliance bladder and 23 with detrusor instability) and 44 with stable bladders. They were matched for age, parity, dystocia, menopause, body mass index, previous vaginal surgery, heavy work, urethral functional length and maximum urethral closure pressure.

RESULTS

At two years follow up, the cure rate of stress incontinence was 95% in the control group (patients with stable bladders) and 75% in detrusor overactivity group (odds ratio 0.1, 95% confidence interval 0.01-0.9, P = 0.02). No significant differences were observed between cured and failed patients according to both detrusor instability indexes. Likewise, mean pre-operative standard cystometric values of cured and failed patients showed no differences.

CONCLUSIONS

Although results were better in women with stable bladders, we believe that the success of the Burch colposuspension in cases with mixed incontinence should be considered satisfactory. No pre-operative cystometric parameter consistently predicting the surgical outcome on stress incontinence was identified.