Cervical Dysplasia in Adolescents

BACKGROUND

Although the incidence of cervical dysplasia in adolescents is increasing, a paucity of data exists regarding the outcomes of adolescents with Pap test abnormalities. We determined the natural history and outcome of adolescents with low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL).

METHODS

A review of all women aged 18 years or younger with a cytologic diagnosis of LSIL or HSIL between 1997 and 2003 was performed. Follow-up cytologic and histologic samples were evaluated. The most significant abnormality was recorded for each patient. Rates of regression, persistence, and progression were calculated.

RESULTS

A total of 646 adolescents were identified. Follow-up was available for 477 teenagers with LSIL and for 55 with HSIL. Among adolescents with LSIL, 146 (35%) had negative follow-up. Low-grade abnormalities (atypical squamous cells of undetermined significance, LSIL, and cervical intraepithelial neoplasia grade 1) were seen in 199 (47%), whereas high-grade abnormalities were documented in 77 (18%). After 36 months, 62% had regressed, whereas 31% had progressive dysplasia. For the HSIL cohort, negative follow-up was documented in 12 (21.8%) adolescents, and 15 (27.3%) had low-grade abnormalities, whereas more than one half (50.9%) were found to have a high-grade abnormality. At 36 months, 31% of HSIL subjects had progressed to cervical intraepithelial neoplasia 3.

CONCLUSION

Adolescents with LSIL and HSIL cytology are at significant risk for progression to high-grade cervical abnormalities. The rate of development of high-grade cervical abnormalities in adolescents is similar to adults. Adolescents with cytologic abnormalities mandate close follow-up.

LEVEL OF EVIDENCE

II-3.

Preoperative lymph node staging of early-stage cervical carcinoma by [18F]-fluoro-2-deoxy-D-glucose-positron emission tomography

BACKGROUND

Increasing evidence has documented the value of positron emission tomography (PET) in oncology, but only limited data are available comparing PET findings with the pathologic status of regional lymph nodes in patients with cervical carcinoma. The objective of this study was to determine the sensitivity and specificity of PET in detecting lymph node metastasis in women with early-stage cervical carcinoma.

METHODS

The authors performed a retrospective review of all patients with Stage IA-IIA cervical carcinoma who underwent PET before surgery from 1999 to 2004. The status of the regional lymph nodes was correlated with lymph node pathology.

RESULTS

Fifty-nine patients were identified. Pelvic lymph node metastases were present in 32% of the patients and were detected by PET with a sensitivity of 53%, a specificity of 90%, a positive predictive value (PPV) of 71%, and a negative predictive value (NPV) of 80%. Paraaortic lymph node disease was present in 9% of patients and was detected by PET with a sensitivity of 25%, a specificity 98%, a PPV of 50%, and an NPV of 93%. The mean size of the tumor deposits was larger in the PET-positive pelvic nodes (15.2 mm; range, 2-35 mm) than in the PET-negative lymph nodes (7.3 mm; range, 0.3-20 mm; P = 0.002). Computed tomography (CT) scans were obtained before surgery in 42 patients. The combined sensitivity of PET and CT in these patients was 75%. PET alone detected 9 (36%) of the positive lymph node groups, whereas CT alone detected 3 (12%) of the positive lymph node groups. Neither PET nor CT detected the positive lymph node groups in 8 patients (32%).

CONCLUSIONS

Pathologic validation of PET imaging demonstrated a low sensitivity and a high specificity for PET in patients with early-stage cervical carcinoma.

A comparison of stages IB1 and IB2 cervical cancers treated with radical hysterectomy. Is size the real difference?

OBJECTIVE

To compare stages IB1 and IB2 cervical cancers treated with radical hysterectomy (RH) and to define predictors of nodal status and recurrence.

METHODS

Patients with stage IB cervical cancers undergoing RH between 1990 and 2000 were evaluated and clinicopathological variables were abstracted. The perioperative complication rate, estimated blood loss (EBL), and OR time were also tabulated. Variables were analyzed using X(2) and t tests. Disease-free survival (DFS) was calculated by Kaplan-Meier method. Multivariate analysis was performed via stepwise logistic regression. Cox-proportional hazards were used to identify independent predictors of recurrence.

RESULTS

RH was performed on 109 stage IB1 and 86 stage IB2 patients. Mean age, EBL, and perioperative complication rates were similar. Overall, 38 patients (14 IB1 vs. 24 IB2) had positive nodes (P = 0.01) including 9 patients with positive para-aortic nodes (2 IB1 and 7 IB2). Parametrial involvement (PI) and outer 2/3 depth of invasion (DOI) were significantly more common in the IB2 tumors as well. Patients with IB2 disease received adjuvant radiation more frequently than IB1 patients (52% vs. 37%, P = 0.04). Univariate predictors of nodal status included lymphovascular space involvement (LVSI) (P = 0.001), DOI (P = 0.011), PI (P = 0.001), and stage (P = 0.011). Multivariate analysis identified only LVSI (OR 6.4, CI 2.4-17, P = 0. 0002) and PI (OR 8, CI 3.1-20, P = 0. 0001) as independent predictors of positive nodes. With a median follow-up of 35 months, estimates of DFS revealed tumor size (P = 0.008), nodal status (P = 0.0004), LVSI (P = 0.002), PI (P = 0.004), and DOI (P = 0.0004) as significant univariate predictors. Neoadjuvant chemotherapy, age, grade, histology, and adjuvant radiation were not associated with recurrence. The significant independent predictors of DFS were LVSI (ROR 5.7, CI 2-16, P = 0.0064) and outer 2/3 DOI (OR 5.8, CI 2-20, P = 0.0029). Neither tumor size nor nodal status was a significant predictor of DFS.

CONCLUSIONS

The prognosis in stage IB cervical cancer seems to be most influenced by presence of LVSI and DOI and not by tumor size as the staging criteria would suggest. These factors are best determined pathologically after radical hysterectomy. This report contains the largest comparison of IB1 and IB2 patients managed by RH. Tumor size failed to predict recurrence or nodal status when stratified by LVSI, DOI, and PI. Treatment decisions based on tumor size alone should be reconsidered.

Panniculectomy: improving lymph node yield in morbidly obese patients with endometrial neoplasms

OBJECTIVE

Panniculectomy has been used to facilitate pelvic surgery in obese women. The goal of this study was to determine the effect of panniculectomy on staging adequacy and lymph node yield in obese women with endometrial carcinoma undergoing staging laparotomy.

METHODS

A retrospective review of patients with endometrial neoplasms who underwent panniculectomy at the time of hysterectomy was performed. For each subject, two control patients were matched by body mass index (BMI).

RESULTS

Twenty-seven endometrial cancer patients who underwent panniculectomy at the time of staging were identified. Panniculectomy was successfully performed in all 27 patients. While the mean number of pelvic nodes was statistically similar between the two groups (16.2 vs. 13.7) (P = 0.199), the paraaortic node count was higher in patients who underwent panniculectomy (4.3 vs. 2.9) (P = 0.032). A paraaortic node dissection was not feasible in 3 (11.1%) of the panniculectomy patients and in 11 (20.4%) of the controls (P = 0.365). There were no differences in intraoperative or postoperative complications or in survival between the two groups.

CONCLUSION

Among obese women with endometrial cancer, panniculectomy is well tolerated, feasible, and associated with acceptable morbidity. While the clinical significance of an increased paraaortic node count is uncertain, our findings suggest that panniculectomy may enhance operative exposure and facilitate endometrial cancer staging.

Detection of molecular diversity in Bacillus atrophaeus by amplified fragment length polymorphism analysis

Phenotypically, Bacillus atrophaeus is indistinguishable from the type strain of Bacillus subtilis except by virtue of pigment production on certain media. Several pigmented variants of B. subtilis have been reclassified as B. atrophaeus, but several remain ambiguous in regard to their taxonomic placement. In this study, we examined strains within the American Type Culture Collection originally deposited as Bacillus globigii, B. subtilis var. niger, or Bacillus niger using 16S rRNA gene sequencing and amplified fragment length polymorphism (AFLP) analysis to determine the level of molecular diversity among these strains and their relationship with closely related taxa. The 16S rRNA gene sequences revealed little variation with one base substitution between the B. atrophaeus type strain ATCC 49337 and the other pigmented bacilli. AFLP analysis produced high-quality DNA fingerprints with sufficient polymorphism to reveal strain-level variation. Cluster analysis of Dice similarity coefficients revealed that three strains, ATCC 31028, ATCC 49760, and ATCC 49822, are much more closely related to B. atrophaeus than to B. subtilis and should be reclassified as B. atrophaeus. A very closely related cluster of B. atrophaeus strains was also observed; this cluster was genetically distinct from the type strain. The level of variation between the two groups was approximately the same as the level of variation observed between members of the two B. subtilis subspecies, subtilis and spizizenii. It is proposed that the cluster of strains typified by ATCC 9372 be designated a new subspecies, B. atrophaeus subsp. globigii.

Prenatally diagnosed human caudal appendage: a case report

BACKGROUND

The caudal appendage, or human tail, is a rare congenital anomaly that arises from the lumbosacrococcygeal region.

CASE

A pregnant woman was referred after ultrasound revealed a possible neural tube defect. A sonogram in our unit revealed a posterior, echogenic protrusion superior to the fetal buttocks. Examination of the infant revealed a fetal caudal appendage at the level of S-4. Ultrasound imaging of the neonatal spine demonstrated a tethered spinal cord extending to the level of S-4 and exiting toward the caudal appendage.

CONCLUSION

A fetal caudal appendage should be included in the differential diagnosis of an echogenic protrusion near the lumbosacral spine on ultrasound. The finding of a caudal appendage in a neonate mandates a careful search for an underlying spinal cord defect.

Morbidity of cytoreductive surgery in the elderly

OBJECTIVES

While ovarian cancer is often seen in elderly patients, such women are often not treated as aggressively as younger patients. In this study, we evaluated the feasibility and morbidity of cytoreductive surgery in the elderly.

STUDY DESIGN

A retrospective review was performed of all patients with epithelial ovarian carcinoma who underwent exploratory laparotomy. Patients were stratified by age into those younger than 70 years of age and those 70 years of age and older.

RESULTS

A total of 175 patients, 129 (74%) in the younger cohort and 46 (26%) in the older cohort, were identified. Optimal cytoreduction to a largest tumor diameter of <1 cm was possible in 82% of the younger patients vs 81% of the elderly (P =1.00). The stage distribution, complication rate, duration of hospital stay, and survival were similar between the groups.

CONCLUSION

Aggressive surgical cytoreduction is both safe and feasible in elderly patients. Advanced age should not be considered a contraindication to cytoreductive surgery.

Is hypotonic dysfunctional labor associated with hypophosphatemia?

OBJECTIVE

The purpose of this study was to determine whether hypotonic dysfunctional labor is associated with hypophosphatemia.

STUDY DESIGN

We conducted a prospective nested case control study of term women who were in active labor. Serum phosphate samples were drawn at admission with active labor and before delivery. Phosphate concentration was compared between control subjects and women with hypotonic, dysfunctional uterine contractions.

RESULTS

Both serum samples were available for 90 women. Hypophosphatemia was documented in 14% of the participants. There was no significant difference in phosphate concentration between the 2 groups either at admission or before delivery. The mean decrease in phosphate concentration between admission and delivery was similar between the 2 cohorts.

CONCLUSION

Although transient hypophosphatemia is found commonly in laboring women, hypotonic dysfunctional contractions are not associated with mild hypophosphatemia.

Synchronous ovarian metastases at the time of laparotomy for colon cancer

OBJECTIVE

The aim of the study was to identify clinical features, define prognostic factors and optimize treatment in patients with colorectal cancer with synchronous ovarian metastases at the time of initial diagnosis.

METHODS

A retrospective analysis of patients treated by the gynecologic oncology service at Barnes Jewish Hospital between 1990 and 2001 was performed. Twenty-eight patients with colorectal carcinomas with synchronous ovarian metastases at the time of diagnosis were identified. Clinical and pathological characteristics were evaluated, and survival was analyzed by the method of Kaplan and Meier.

RESULTS

Abdominal pain was the most common symptom at presentation. Only 14% of the patients presented with gastrointestinal bleeding. Fifty-four percent of patients who underwent barium enema had intrinsic colonic lesions, while 40% of patients who had endoscopies performed had their colonic tumors identified. Preoperatively colon cancer was considered in the differential diagnosis of 71% of the patients. At exploration, the ovarian metastases were significantly larger than the primary colon tumors. Overall, 68% of patients had intraperitoneal nodal metastasis and 86% had transmural extension of their tumors. The only pathological variable associated with survival was tumor grade. The median disease-free survival was 10.3 months while the median overall survival was 18.4 months.

CONCLUSION

Most patients with colon cancer with synchronous ovarian metastases present with vague symptoms. At exploration, locally advanced tumors and other distant metastases such as in the liver are common. Surgical management should include extirpation of the primary tumor and any bulky ovarian metastases. Cytoreduction may be considered in highly selected patients.

Atypical Squamous Cells of Undetermined Significance in Girls and Women

OBJECTIVE

To estimate the outcome of adolescents with atypical squamous cells of undetermined significance (ASC-US) on cytology.

METHODS

A review of ASC-US cytology in girls and women aged 10-19 years between 1995 and 1999 was performed. The cytologic and histologic follow-up of each patient was evaluated. The outcome was recorded as the most significant (highest grade) subsequent cervical smear or biopsy.

RESULTS

Overall, 535 of 7897 (6.8%) cervical cytologic specimens were reported as ASC-US. The study group consisted of 398 patients for whom pathologic follow-up was available. The mean duration of follow-up was 19 months. Follow-up consisted of repeat cytology in 251 (63%) patients and colposcopy with cervical biopsies and/or endocervical curettage in 147 (37%) of the adolescents. Two hundred fifty-three (64%) adolescents had no pathologic abnormalities on follow-up. Persistent ASC-US was identified in 65 (16%), low-grade squamous intraepithelial lesions/cervical intraepithelial neoplasia (CIN) 1 was found in 44 (11%) and high-grade squamous intraepithelial lesions/CIN 2 or 3 occurred in 36 (9%) of the adolescents. No cases of invasive carcinoma were found.

CONCLUSIONS

Among adolescents with ASC-US, the rate of squamous intraepithelial lesions/CIN is similar to that of adults. Although the optimal management of ASC-US in adolescents is unknown, these patients warrant close follow-up.

LEVEL OF EVIDENCE

III

Cervical carcinoma in the elderly

BACKGROUND

Advanced age often is considered a poor prognostic factor for cervical carcinoma. The authors investigated the patterns of care and treatment outcomes of elderly women with cervical carcinoma.

METHODS

A hospital-based tumor registry was used to identify patients with invasive cervical carcinoma who were treated between 1986 and 2003. Patients were divided into 2 cohorts: women age < 70 years and women age > or = 70 years. Survival was examined using the Kaplan-Meier method. Single and multivariate Cox proportional hazards modeling was used to estimate hazard ratios with 95% confidence intervals (95% CI).

RESULTS

In total, 1582 patients were identified, including 1385 patients age < 70 years and 197 patients age > or = 70 years. The elderly patients presented with more advanced stage tumors at diagnosis (P <0.0001) and were more likely to have nonsquamous neoplasms (P=0.002). A marked difference in treatment was noted for the elderly cohort, even after stratifying by disease stage. Only 16% of the older patients underwent surgical treatment compared with 54% of the younger patients (P <0.0001). Elderly women were 9 times more likely to receive no treatment (P <0.0001). In a multivariate model of known prognostic factors, the hazard ratio for death from any cause in women age > 70 years was 2.1 (95% CI, 1.5-3.0). The hazard ratio for death from cervical carcinoma in the elderly women was 1.6 (95% CI, 1.1-2.5).

CONCLUSIONS

Age is an important factor in the allocation of treatment and survival for patients with cervical carcinoma. Elderly women with cervical carcinoma are more likely to receive primary radiotherapy, to forego treatment, and to die from their disease.

Liquid-based cytology for the postirradiation surveillance of women with gynecologic malignancies

OBJECTIVE

To determine the performance of liquid-based cytology using ThinPrep in the postirradiation surveillance of women with gynecologic malignancies.

METHODS

Patients with endometrial and cervical cancer treated with primary or adjuvant radiotherapy between 2000 and 2002 were identified. Details regarding tumor characteristics, treatment, and cytologic and histologic results were abstracted. Binomial variables were compared with the chi-square test. The performance characteristics of liquid-based cytology were evaluated.

RESULTS

A total of 302 liquid-based cytologic samples from 121 women were evaluated. Overall, 294 (97.4%) of the specimens were adequate for interpretation and 132 (44.9%) were within normal limits. Benign cellular changes, including benign radiation changes, were identified in 141 (47.6%). Atypical squamous cells (ASCUS) were found in 15 (5.1%), recurrent dysplasia in 4 (1.3%), and recurrent carcinoma in 2 (0.7%). Follow-up of the 15 ASCUS smears revealed 13 (86.7%) normal smears and 2 cases of squamous intraepithelial lesions. Benign findings were noted in three of the four smears with SIL. The sensitivity for the detection of SIL was 33%, the specificity 99%, and the positive predictive value (PPV) 25%. Of the 4 patients with local recurrences, 2 were detected by cytology. The sensitivity for the detection of recurrent carcinoma was 50%, with a specificity and PPV of 100%.

CONCLUSIONS

ThinPrep for the surveillance of women with gynecologic malignancies treated with radiotherapy is associated with a high rate of satisfactory samples and a low rate of equivocal and ASCUS cytology.

Acute abdominal pain with a calcified pelvic mass

A case of a 15-year-old with a calcified pelvic mass is presented with a review of the differential diagnosis.

Kytococcus sedentarius, the organism associated with pitted keratolysis, produces two keratin-degrading enzymes

AIMS

To determine characteristics of the extracellular enzyme activity of Kytococcus sedentarius on human callus.

METHODS AND RESULTS

A concentrate of a continuous culture supernatant fluid of K. sedentarius, which had callus-degrading activity, was subjected to a series of chromatographic purification procedures. The enzyme activity was found to be attributable to two proteases. These were capable of degrading both native callus and extracted keratin polypeptides and were purified to homogeneity, as shown by SDS-PAGE with silver staining. The enzymes P1 and P2 were 30 kDa and 50 kDa in size with isoelectric points of 4.6 and 2.7, respectively. The optimum conditions for callus-degrading activity were 40 degrees C, pH 7.1 for P1 and 50 degrees C, pH 7.5 for P2. P2 displayed increased activity in the presence of 800 mmol l(-1) NaCl and both enzymes were inhibited by PMSF (1 mmol(-1) Phenylmethylsulphoryl fluoride) and 1 mmol l(-1) EDTA. The main enzyme cleavage sites were Lys-Trp, Val-Lys, Gly-Asp and Asp-Arg, as determined after incubation of P1 and P2 with the beta-chain of insulin.

CONCLUSIONS

K. sedentarius produces two extracellular enzymes that independently degrade natural, insoluble human callus. Both enzymes are serine proteases and have cleavage preference sites that are present in a range of human keratins.

SIGNIFICANCE AND IMPACT OF THE STUDY

The identification, in K. sedentarius cultures, of two enzymes which can degrade human callus strengthens the hypothesis that this organism is responsible for the pitting in human epidermis observed in pitted keratolysis. These enzymes may be of commercial use in the biodegradation of a range of keratin polymers, biological washing powders and in the treatment of unwanted callus on human skin.

Placental site trophoblastic tumor presenting with a pneumothorax during pregnancy

BACKGROUND

Placental site trophoblastic tumor is a rare form of gestational trophoblastic disease that commonly presents with vaginal bleeding and amenorrhea after pregnancy.

CASE

A women with a normal gestation at 37 weeks presented with a pneumothorax. The patient underwent placement of a chest tube and a subsequent thoracoscopic pulmonary bullous resection for persistence of the pneumothorax. Histological examination of the specimen revealed a metastatic placental site trophoblastic tumor.

CONCLUSION

Gestational trophoblastic disease must be considered in the differential diagnosis of pneumothorax during pregnancy.

Primary peritoneal carcinoma presenting as adenocarcinoma on a Pap smear. A case report

BACKGROUND

Primary peritoneal carcinoma is an uncommon malignancy that usually presents with gastrointestinal symptoms from abdominal carcinomatosis.

CASE

A postmenopausal woman presented with vaginal bleeding and adenocarcinoma cells on a Pap smear. Colposcopy, endocervical and endometrial curettage, mammography, colonoscopy and pelvic ultrasound were all normal. Computed tomography revealed a large omental cake and ascites, and the CA-125 level was elevated, 2,907 IU/mL. Exploratory laparotomy revealed a primary peritoneal carcinoma with abdominal carcinomatosis.

CONCLUSION

Primary peritoneal carcinoma should be considered in the differential diagnosis of adenocarcinoma cells arising on a Pap smear in the absence of cervical and endometrial cancer.

Human papillomavirus: emerging trends in detection and management

Cervical cancer continues to be a major epidemiologic problem in developed and underdeveloped nations alike. Current screening practices rely on cervical cytology for the early detection of cervical neoplasms. It has now been demonstrated that over 99% of cervical carcinomas are positive for human papillomavirus (HPV) DNA. This article reviews the currently available methods of HPV detection as well as emerging strategies for the implementation of HPV testing into clinical practice.

A fast method for predicting amino acid mutations that lead to unfolding

Amino acid mutation(s) that cause(s) partial or total unfolding of a protein can lead to disease states and failure to produce mutants. It is therefore very useful to be able to predict which mutations can retain the conformation of a wild-type protein and which mutations will lead to local or global unfolding of the protein. We have developed a fast and reasonably accurate method based on a backbone-dependent side-chain rotamer library to predict the (folded or unfolded) conformation of a protein upon mutation. This method has been tested on proteins whose wild-type 3D structures are known and whose mutant conformations have been experimentally characterized to be folded or unfolded. Furthermore, for the cases studied here, the predicted partially folded or denatured mutant conformation correlate with a decrease in the stability of the mutant relative to the wild-type protein. The key advantage of our method is that it is very fast and predicts locally or globally unfolded states fairly accurately. Hence, it may prove to be useful in designing site-directed mutagenesis, X-ray crystallography and drug design experiments as well as in free energy simulations by helping to ascertain whether a mutation will alter or retain the wild-type conformation.

Internal quality control in virology: validation of immunoassays using a personal computer spreadsheet

Design of a spreadsheet to evaluate the performance of internal quality control sera used for the validation of immunoassays in virology is described. Developed using Microsoft Excel 97, it can set target limits and analyse control data by application of Westgard quality control rules. It also provides a permanent record of all relevant information concerning each assay run, including action taken to rectify unacceptable performance.

Lutein and zeaxanthin in the diet and serum and their relation to age-related maculopathy in the third national health and nutrition examination survey

Relations of the carotenoids lutein and zeaxanthin in the diet and serum to photographic evidence of early and late age-related maculopathy (ARM) among persons over age 40 years (n = 8,222) were examined. Inverse relations of these carotenoids in the diet or serum to any form of ARM were not observed overall. There was a direct relation of dietary levels to one type of early ARM (soft drusen). However, relations differed by age and race. In the youngest age groups who were at risk for developing early (ages 40-59 years) or late (ages 60-79 years) ARM, higher levels of lutein and zeaxanthin in the diet were related to lower odds for pigmentary abnormalities, one sign of early ARM (odds ratio among persons in high vs. low quintiles = 0.1, 95 percent confidence interval: 0.1, 0.3) and of late ARM (odds ratio = 0.1, 95 percent confidence interval: 0.0, 0.9) after adjustment for age, gender, alcohol use, hypertension, smoking, and body mass index. Relations of these carotenoids to ARM may be influenced by age and race and require further evaluation in separate populations and in prospective studies.