Development of invasive disease in 433 women treated for vulvar, vaginal or perianal intraepithelial neoplasia

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Background: The incidence of intraepithelial neoplasia (IN) of the lower anogenital tract is increasing. Due to small case-series, the malignant potential of treated high-grade IN is not well defined and risk factors for progression are not established. Methods: Patients with IN of the vulva (VIN), vagina (VAIN) and perianal skin (PAIN) were identified in the electronic databases of three university colposcopy clinics. Inclusion criteria were biopsy proven IN grade 2–3 (high-grade) and no history of vaginal, vulvar or anorectal cancer. Excluded were patients with the diagnosis of invasive disease within one year from initial diagnosis of IN. Results: 442 patients were identified from 1977 to 2005 with a mean follow up of 69.9 ± 56.1 months. Initial diagnosis was VIN III in 75.3%, VIN II in 17.2%, VAIN II in 4.3%, VAIN III in 2%, and PAIN II/III in 1.1% of patients. Mean age at initial diagnosis was 47.1 ± 14.1 (range, 18–102). Initial treatment was biopsy and laser evaporation in 61.5%, surgical excision in 32.8%, and other locally destructive methods in 3.1% of patients. 9 patients refused any treatment (2.0%). In the 433 treated patients, recurrent disease (e.g. diagnosed >1 year after initial diagnosis) occurred in 32.2%. In patients with a follow up longer than 5 years, 14.4 % were still experiencing recurrences. In multivariate analysis, immunosuppression (OR: 2.33, 95% CI 1.06–5.06, p = 0.035) was associated with recurrence but not smoking, age or histological grade. Progression to invasive disease occurred in 3.8% of treated patients within a mean time of 7.9 ± 6.8 years (range, 1.3–24.5). In multivariate analysis, immunosuppression (OR:3.31, 95% CI 1.01–10.93, p = 0.049) and smoking (OR:3.12, 95% CI 1.07–9.08, p = 0.037) were independent risk factors for progression. Conclusions: Anogenital IN is a chronic disease in a substantial proportion of patients. The malignant potential is remarkably high despite repeated treatments. Therefore, long lasting surveillance is mandatory, especially in immunosuppressed or smoking patients.

No significant financial relationships to disclose.

A distinct molecular profile associated with mucinous epithelial ovarian cancer

Mucinous epithelial ovarian cancers (MOC) are clinically and morphologically distinct from the other histological subtypes of ovarian cancer. To determine the genetic basis of MOC and to identify potential tumour markers, gene expression profiling of 49 primary ovarian cancers of different histological subtypes was performed using a customised oligonucleotide microarray containing >59 000 probesets. The results show that MOC express a genetic profile that both differs and overlaps with other subtypes of epithelial ovarian cancer. Concordant with its histological phenotype, MOC express genes characteristic of mucinous carcinomas of varying epithelial origin, including intestinal carcinomas. Differences in gene expression between MOC and other histological subtypes of ovarian cancer were confirmed by RT–PCR and/or immunohistochemistry. In particular, galectin 4 (LGALS4) was highly and specifically expressed in MOC, but expressed at lower levels in benign mucinous cysts and borderline (atypical proliferative) tumours, supporting a malignant progression model of MOC. Hence LGALS4 may have application as an early and differential diagnostic marker of MOC.

[Organ preservation, multimodal radical tumor therapy and reduction of therapy-related morbidity--development of diagnostics and therapy of endometrial carcinoma]

Endometrial carcinoma is the most frequent genital malignoma in women. Considering the tumor-biological and prognostically very different subtypes of endometrial carcinoma, an individual therapeutic strategy plays a very important role. Besides the question of an individualized organ-preserving procedure for women who wish to have a baby, the reduction of morbidity by minimally invasive laparoscopic/vaginal surgery is discussed. While adjuvant gestagen therapy is not useful, platinum-containing chemotherapy seems to be effective in certain risk situations. The indication of lymphonodectomy with regard to staging as well as the effect of adjuvant radiation therapy for local control are undisputed. In view of a postulated curative effect, the results of the ongoing prospective studies will make things clearer.

Diagnostik und Therapie maligner Ovarialtumoren 2005: Die Empfehlungen der Kommission Ovar der AGO

Recommendations for diagnosis and treatment of malignant ovarian tumors with regard to the most recent data were worked out in a consensus process and valued by level of evidence (LoE) and grade of recommendation (GoR) of the Canadian Task Force for Preventive Health Care by the members of the Kommission Ovar der Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) in June 2005. A short version of these guidelines is presented.

[Overactive bladder: prospects and limitations of botulinum toxin]

Botulinum toxin is the most potent poison known to man. It is produced by Clostridium botulinum and consists of a heavy chain which is responsible for the internalization of the toxin into the cytosol and a light chain that has the ability to cleave proteins within the nerve terminal. As those proteins are essential for normal vesicular transport and fusion of acetylcholine, botulinum toxins are able to prevent its release at the presynaptic membrane, resulting in a chemodenervation of the detrusor muscle after intravesical injection of the toxin and an impressive reduction of symptoms of overactive bladder. Clinical studies show success rates between 60 and 96% for neurogenic and non-neurogenic detrusor overactivity. Thus, application of botulinum toxin to the lower urinary tract appears to be an efficient, safe and minimally invasive procedure.

[Urinary incontinence and descensus genitalis--the silent sickness]

In the last few years, urogynaecology has become a very innovative gynaecological subspecialty. New findings have led to a multitude of different medicinal and operative therapy options. Stress incontinence can be improved by sling procedures in more than 80% of patients. Likewise, new drugs to treat stress incontinence have been available for some time. Injections of botulinum toxin A into the detrusor muscle are a promising treatment strategy in cases of therapy-resistant overactive bladder.

The role of surgery in recurrent ovarian cancer

The role of cytoreductive surgery (CS) in recurrent ovarian cancer (ROC) has not been clearly defined. We performed a retrospective study evaluating criteria for CS in ROC. Twenty-five institutions documented their patients with CS for invasive epithelial ROC performed 2000-2003. Two hundred sixty-seven patients were included. Complete tumor removal was achieved in 133 patients (50%). Complete resection was associated with prolonged survival compared to surgeries with residual tumor. Median survival of patients without residual tumor was 45.3 months and of patients with residual tumor, irrespective of its size, 19.0 months (HR 4.33; 95% CI 2.53-7.43; P < 0.0001). In a multivariate analysis, the following factors showed a significant influence on the probability to achieve a postoperative residual tumor of 0 mm: absence of ascites (<500 vs > or =500 mL: HR 4.63; 95% CI: 1.81-11.76; P= 0.0001), good performance status Eastern Cooperative Oncology Group (ECOG) 0 vs >0: HR: 2.41; 95% CI: 1.41-4.08; P= 0.001, and low FIGO stage at primary diagnosis (FIGO I/II vs III/IV: HR 1.87; 95% CI: 1.04-3.37; P= 0.036). Significant factors for survival after surgery for recurrence in a multivariate analysis were achievement of complete resection (residual tumor at surgery for recurrence 0 vs >0 mm: HR 2.86; 95% CI: 1.66-4.93; P < 0.001), absence of ascites (<500 vs > or =500 mL: HR 2.09; 95% CI: 1.18-3.71; P= 0.012), and application of a platinum-containing chemotherapy (platinum-containing chemotherapy vs others: HR 1.83; 95% CI: 1.16-2.88; P= 0.009). Only patients with complete resection seem to benefit from CS. This new panel of selection criteria will be evaluated in a prospective study.

Iodine excretion in regions of Ukraine affected by the Chornobyl Accident: experience of the Ukrainian-American cohort study of thyroid cancer and other thyroid diseases

Urinary iodine concentrations were measured in 11,926 subjects who are participants in the Ukrainian-American Cohort Study of Thyroid Cancer and Other Thyroid Diseases Following the Chornobyl Accident. Measurements were made in two time periods corresponding to the first and second thyroid screening cycles (1998-2000, 2001-2003). These time periods fall before and after initiation of a government program to increase iodine sufficiency. Median urinary iodine concentrations did increase in the later time period compared to the earlier [47.5 microg/L, 95% confidence interval (CI) 46.5-48.9 microg/L versus 41.7 microg/L, 95% CI 40.4-42.5 microg/L], but levels remained in the mild-to-moderate iodine deficiency range as defined by the World Health Organization (WHO), indicating the need for further efforts at iodination. In both time periods, urinary iodine levels were found to vary by place of residence and were lower in rural compared to urban areas. Iodine status needs to be considered when evaluating risk of thyroid cancer and other thyroid diseases.

[Contraception in young adolescents]

The continuing increase in teenage pregnancies and abortions calls for more effective sex education on the one hand, including a detailed explication of the (perfectly normal) changes an adolescent body is undergoing, but we also need to understand the way teenagers actually do use contraceptives. Modern contraception for teenagers should not cause any side effects and its efficacy must not be linked to compliance. Gynaecologists must acquaint themselves with the laws covering the prescription of contraceptives to adolescents. Whether hormonal contraceptives for men are also suitable for teenage boys remains to be seen. Advising mentally or physically handicapped teen-agers or those with chronic diseases on their contraceptive options is particularly challenging. Adolescents are more prone to contract HPV infections and thus need to be screened, counselled and told about the association between HPV and cervical dysplasia.

[Gynaecological emergencies]

Any primary care doctor should be prepared to encounter and to handle gynaecological emergencies in patients, even those in critically ill states. We want to present a concentrated review on some of the "hard" gynaecological emergencies like extrauterine pregnancy, abortion, and malignancy associated hemorrhage. Moreover, there is another group of patients with "soft" gynaecological emergencies, as for instance the distressing symptoms caused by a vulvovaginal infection. Despite most advanced strategies for early detection, emergency situations caused by ectopic pregnancies still happen. Ectopic pregnancies are most frequently located in the fallopian tubes. Tubal abortion and tubal rupture are very demanding situations in the course of a tubal pregnancy that need immediate assessment and treatment, and maybe emergency life support. Of all the different types of abortion, incomplete abortion is most likely to provoke life-threatening situations. Incomplete expulsion of the products of conception may lead to severe bleeding from the uterus. Immediate uterine curettage is required in this case. Advanced stages of cervical cancer may cause life-threatening hemorrhages as a result of vascular arrosion. Ovarian torsion is a gynaecological emergency characterised by acute abdominal pain.

[Therapy of breast cancer--change from radical to quality-controlled individualized treatment]

The treatment of breast cancer is changing continually. Thus, sentinel lymph node dissection is considered today as standard in the therapy of small unifocal breast carcinoma with clinically negative axillary lymph nodes. Concerning adjuvant therapy, the 9th Early Adjuvant Breast Cancer Meeting, along with a consensus conference, took place in Saint Gall on January 26-29, 2005. The publication of the corresponding congress report is expected for early summer of 2005.

Von der Schuldfrage zur Fehlerkultur in der Medizin

The number of liability cases but also the size of individual claims due to alleged treatment errors are increasing steadily. Spectacular sentences, especially in the USA, encourage this trend. Wherever human beings work, errors happen. The health care system is particularly susceptible and shows a high potential for errors. Therefore risk management has to be given top priority in hospitals. Preparing the introduction of critical incident reporting (CIR) as the means to notify errors is time-consuming and calls for a change in attitude because in many places the necessary base of trust has to be created first. CIR is not made to find the guilty and punish them but to uncover the origins of errors in order to eliminate them. The Department of Anesthesiology of the University Hospital of Basel has developed an electronic error notification system, which, in collaboration with the Swiss Medical Association, allows each specialist society to participate electronically in a CIR system (CIRS) in order to create the largest database possible and thereby to allow statements concerning the extent and type of error sources in medicine. After a pilot project in 2000-2004, the Swiss Society of Gynecology and Obstetrics is now progressively introducing the 'CIRS Medical' of the Swiss Medical Association. In our country, such programs are vulnerable to judicial intervention due to the lack of explicit legal guarantees of protection. High-quality data registration and skillful counseling are all the more important. Hospital directors and managers are called upon to examine those incidents which are based on errors inherent in the system.

Malignant perivascular epithelioid cell tumor (PEComa) arising in the broad ligament

Malignant perivascular epithelioid cell tumor (PEComa) is an extremely rare mesenchymal neoplasm mostly composed of HMB-45-positive epithelioid cells with clear-to-eosinophilic cytoplasm, a propensity for perivascular distribution and a coexpression of smooth muscle markers. The uterus seems to be one of the most prevalent sites of involvement, although only 14 cases of uterine PEComa have been described. We report the case of a 51-year-old woman with a PEComa arising in the broad ligament. She was treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic radiation, and remains without evidence of disease 15 months after diagnosis. This is, to the best of our knowledge, the first report of a malignant PEComa arising in the broad ligament. To correctly diagnose PEComa, an extensive immunohistochemical panel is essential. As PEComas can behave in an aggressive manner, careful follow-up is warranted.

Eosinophilic pericarditis: a rare complication of idiopathic hypereosinophilic syndrome in a child

We describe an 18-month-old child with idiopathic hypereosinophilic syndrome (IHES) who presented with fever, and cervical lymphadenopathy. Chest X-ray showed marked cardiomegaly, and echocardiogram revealed large pericardial effusion. Other causes of pericarditis were excluded. Despite the initiation of steroid therapy, signs of impending cardiac tamponade developed. Pericardiocentesis yielded bloody fluid with a white blood count of 14,800/mm3, of which 23% were eosinophils. The child recovered after pericardial drainage and prolonged systemic steroid therapy. Eosinophilic pericarditis is a rare but potentially dangerous complication of IHES.