[Malignant tumors of the female genitalia in childhood--yesterday, today and tomorrow]

Genital tumors in children and adolescents represent 1.5 to 2.0% of al malignancies in these age groups. Organ incidence differs from that in adult women. In children and in young adolescents non-epithelial gynaecological tumors predominate, while carcinomas are rare and their incidence rises with the age of girls. Malignant tumors of the external genital are very rare (sarcomas of the soft tissues). Malignancies of vagina are represented by the embryogenic rabdomyosarcoma, yolk sack tumor and tumor of pale cells or vaginal adenocarcinoma. All these tumors are highly malignant. Cytostatics are used as the basic therapy and only later the less radical surgery is recommended. Radiotherapy is used in chemoresistant tumors. Vaginal bleeding of the premenarcheal girl is an early symptom and requires immediate examination, including vaginoscopy. Tumors of uterus in childhood do not occur and they are rare in postmenarcheal girls. Ovarian tumors represent about 1.5% of all tumors in childhood and adolescence and about 95% of all gynaecologic tumors. They differ in types from those of adults: Epithelial tumors (carcinomas) do not occur in childhood, germinal and gonadal stromal tumors are typical in this age. Mature differentiated teratomas are usually benign and the less differentiated they are, the worse biological effect they have (not mature or mixed teratomas). It seems that nowadays the proportion of immature and mixed teratomas has been rising. Dysgerminom occurs more frequently in Y-chromosome karyotypes. It has malignant progression with early propagation along lymph vessels into the lymph nodes. Beside ovarectomy, also lymphadenectomy at the affected side is performed and the treatment proceeds with chemotherapy. For the prognostic reasons, immunological examinations, DNA ploidity identification and other tests are recommended. Gonadal stromal tumors are always unilateral, malignant, and frequently hormonally active, but they usually have a good prognosis. In order to preserve fertility of the young girl with ovarian tumors, uterus should be spared as well as the macroscopically healthy contra-lateral ovarium. To protect gonad from the adverse effects of oncological treatment, pharmacologically induced regression to premenarcheal stadium has been tested. Present development of paediatric and adolescent gynaecology is aimed to preserve for patients with tumors all prospects of future pregnancy, either in the natural way or using methods of assisted reproduction with a donated oocyte. Complex treatment of gonadal malignancies in childhood in future will be aimed not only at the lifesaving but also at the preservation of the highest possible quality of life, including the motherhood.

[The Barnett-Macku method of anterior colporrhaphy in the prevention and treatment of urinary stress incontinence in women with cystocele]

OBJECTIVE

The evaluation of the success rate in prevention and treatment of stress incontinence in patients with cystocele operated by Barnett-Macku modification of anterior colporrhaphy.

DESIGN

Retrospective clinical trial.

SETTING

Obstetrics and Gynecology Department, Charles University 2nd Medical Faculty and Teaching Hospital Motol, Prague.

METHODS

Comparative questionnaire study of 41 patients operated between 1998 and 2000 for cystocele by Barnett-Macku modification of anterior colporrhaphy and the control group of 75 patients operated by Stoeckel modification. Preoperative examination included history, gynecological examination and evaluation of urinary continence. Body mass index, obesity, age, parity and hormonal status were recorded in the time of surgery. Stress and urge incontinence, lower urinary tract infections, hormonal therapy, recurrency of the prolapse and quality of life improvement were evaluated in follow-up. Yes-no logistic regression test and chi 2 test were used for the statistical analysis.

RESULTS

In the group of patients operated for cystocele by Barnett-Macku modification of anterior colporrhaphy statistically significant higher success rate in the prevention and treatment of concomitant stress urinary incontinence was demonstrated. Prophylactic effect of the procedure was also documented by the fact that no one stress incontinent woman after surgery appeared in this group.

CONCLUSION

Barnett-Macku modification of anterior colporrhaphy is reliable and successful contribution into the register of reconstructive vaginal operations primary for the treatment of cystocele and secondary for the prevention of latent and treatment of concomitant stress incontinence.

[Hormone replacement therapy, proliferation in the breast and risk of carcinoma]

OBJECTIVE

The objective of the study was to investigate the changes of histopathological and immunohistochemical parameters of breast tissue among the HRT users.

DESIGN

Prospective, pilot study.

SETTING

Departments of Gynecology and Obstetrics, Pathology and Radiology of the 2nd Medical School, Charles University and the Teaching Hospital Motol, Praha 5, Czech Republic.

METHODS

The samples of breast issue were obtained by core cut biopsy and during the breast surgery procedures in the study group of HRT users (no = 48) and in the control group of women without HRT (n = 22). Proliferation index (Ki-67), expression of ERB2 oncoprotein and hormonal receptors (ER, PR) were examined in the breast tissue in addition to routine histopathological examinations.

RESULTS

We did not record increasing frequency of proliferative and precancerous lesions in the group of HRT users. Ki-67 expression was very low both in HRT users and in the control group of women. The values of estrogen receptors expression in breast tissue samples of women with HRT were similar to the findings in the normal breast. The values of progesterone receptor expression were higher among the HRT users then non-users, but it can be considered as a normal response of breast tissue to hormonal influence. Expression of ERB protein in HRT users was similar to that found in non-users.

CONCLUSION

The findings indicate that HRT has not increased the proliferation rate of the breast tissue in our study group, so this mechanism certainly does not increase the risk of breast cancer.

[What can we expect of raloxifene in the treatment of postmenopausal osteoporosis--views of a gynecologist]

OBJECTIVE

Evaluation of positive properties and side effects of raloxifene treatment with respect to its potential use as agent to improve women's health and quality of life in postmenopausal years.

DESIGN

A review article.

SETTING

Obstetrics and Gynaecology Department, Charles University 2nd Medical Faculty and Teaching Hospital Motol, Prague.

SUBJECT

Estrogen use may protect against osteoporosis and cardiovascular disease, but may increase the risk of breast cancer in long-term treated women and also may increase the risk of irregular uterine bleeding (in combination with gestagen in non-hysterectomized women) in perimenopause and postmenopause. Drugs with tissue-specific estrogenic effects are termed selective estrogen receptor modulators (SERM). Tamoxifen is the first SERM successfully used in the prevention and treatment of breast cancer. Another SERM raloxifene is widely used in the prevention and treatment of postmenopausal osteoporosis, especially in women without climacteric complaints. Therapy with raloxifene increases bone mineral density, lowers serum concentrations of total and low-density lipoprotein cholesterol, and does not stimulate endometrium and breast. Evaluation of another potential positive effects (reducing size of uterine leiomyomas, etc.) warrants further investigation.

CONCLUSION

Raloxifene can be used in postmenopausal women free of climacteric symptoms for the prevention and treatment of postmenopausal osteoporosis with no increased risk of thrombosis and with the advantage of positive side effects during the treatment.

[Regression of hCG in various types of molar pregnancies--clinical course and prognosis]

OBJECTIVE

To evaluate spontaneous regression curves of hCG serum positivity in patients with surgically treated molar pregnancies. Comparison of complete, partial and invasive mole. The study should result in optimalisation of follow up criteria of molar pregnancies in respect to their potential malignant change.

DESIGN

Retrospective comparative clinical study.

SETTING

Obst. Gyn. Dpt., Oncogynecology div., 2nd Medical Faculty, FNM, Charles University Prague, Pathology Dpt., 2nd Medical Faculty, Institute of Biology and Medical Genetics.

METHODS

Evaluation of spontaneous regression curves of serum hCG levels in 104 molar pregnancies. 46 patients with partial hydatiform mole, 48 patients with complete hydatiform mole, 10 patients with invasive mole. Serum hCG levels were detected by radioimunoassay (RIA) in the first period and imunochemoluminisent assay (LIA) in the second period. Regression curves of hCG positivity in particular moles were statistically evaluated by Fischer test and t-test.

RESULTS

There is statistically significant difference in spontaneous regression of hCG positivity in different types of molar pregnancies. Recommended criteria for gestational trofoblastic disease (GTD) diagnosis and follow up are fully applicable in clinical practice. There is exception in partial hydatiform moles, where plateau in hCG regression does not necessarily implicate chemotherapy in patient with good compliance.

CONCLUSION

Early diagnosis of GTD predominantly due to the widespread use of ultrasonography changes classical clinical features of molar pregnancies. Spontaneous regression in hCG positivity in serum is more rapid in patients with partial hydatiform mole, slower in complete hydatiform mole and invasive mole. There is no significant change in malignant potential regarding early detection and treatment.

The frequency of HLA-DRB1 and -DQB1 alleles in cervical cancer cases in the Czech Republic

The distribution of HLA class II DRB1 and DQB1 alleles in cervical carcinoma patients was compared with the frequency of these alleles found in healthy population living in the Czech Republic. The RFLP analysis and PCR-SSP were used for DNA typing. Although the differences in the frequency of DRB1*03, DQB1*02 and DQB1*0303 alleles between the cases and the controls were rather large, corrected P values did not reach significance.

Human papillomavirus genotype spectrum in Czech women: correlation of HPV DNA presence with antibodies against HPV-16, 18, and 33 virus-like particles

Because the biological spectrum of human papillomavirus (HPV) genotypes present in cervical cancer lesions varies according to the geographical region studied, and because little genotype information is available for Central and Eastern European countries, we studied the endemic HPV-genotype spectrum in cervical samples collected from women visiting gynaecological departments of selected hospitals in the Czech Republic. In a series of 389 samples, 171 (44.0%) were positive for HPV DNA using a consensus-primer polymerase chain reaction (PCR). Genotyping of the HPV PCR products was done using dot-blot hybridisation with type-specific oligonucleotide probes and thermocycle DNA sequencing. Twenty-two different HPV types were detected, HPV-16 being the most prevalent type irrespective of severity of the lesions (55.0%). Multiple HPV types were found in 16.4% of our HPV-DNA-positive samples. The prevalence of HPV infection was 23.0% in women with normal findings and 59.4% in patients with cervical neoplasia, and increased significantly with the severity of the disease: 52.9% in low-grade lesions, 58.0% in high-grade lesions, and 73.5% in cervical carcinomas (P for trend < .00001). In the sera of 191 subjects, 89 with normal findings and 102 with different forms of cervical neoplasia, the prevalence of HPV-specific IgG antibodies was tested by an enzyme-linked immunosorbent assay (ELISA) using virus-like particles (VLPs) of HPV-16, -18, and -33. Antibodies were significantly more prevalent in HPV-DNA-positive than in HPV-DNA-negative women and there was no association with age. In agreement with the results of HPV genotyping, antibodies reactive with HPV-16 VLPs were the most frequent and, moreover, their prevalence increased with the cervical lesion severity. About half of the subjects with smears in which either HPV-16 or HPV-33 DNA had been detected possessed antibodies reactive with homotypic VLPs. With HPV-18-DNA-positive subjects, however, fewer than 25% displayed homotypic antibodies. In general, subjects older than 30 years of age had antibodies reactive to HPV-specific VLPs more often than subjects younger than 30 years of age. In women with benign findings, the seropositivity to HPV-16, -18, and -33 VLPs increased with age, whereas in women with cervical neoplasia the seropositivity decreased with age.

[Squamous intraepithelial lesions in young female university students]

The authors investigated the frequency of squamous intraepithelial lesions (SIL) in young women, in particular university students with special attention to morphological signs of the presence of human papilloma virus (HPV) in SIL low grade-SIL, LG-HPV. As compared with data in the world literature, they revealed a significantly lower rate of SIL LG, HPV-2.81% as compared with 5.5% reported in WHO studies of young women. The authors analyzed the biological behaviour of SIL, LG-HPV. As compared with data in the literature on known values of spontaneous regression which are 50-62% in the course of three years, they demonstrated during a time interval from 3 months to 2 years spontaneous regression in 39.1%. Further possibilities of regression in a longer time interval are expected in the group of clinically latent cytologically persistent LG lesions (18.1%) and in the group of patients which after termination of their studies were lost from the records (24.3%). During the investigated time interval no case of progression to a higher grade lesion was recorded. The authors reflect on diagnostic and therapeutic procedures with regard to the application of results of HPV typing.

[Gynecologic oncology--present trends]

The incidence of all malignant tumours of the female reproductive organs in our country is on average by 40% higher than the worldwide incidence and with the exception of carcinoma of the uterine cervix it is still slowly rising. Gynaecological oncology emphasizes: prevention with accurate classification of premalignant changes to ensure adequate treatment; radical surgery primarily in invasive forms as well as with regard to staging as a prerequisite for indication of adjuvant treatment; interdisciplinary team cooperation which indicates without time losses all therapeutic steps, incl. inoperable tumours, and ensures permanent follow-up.

[Pregnancy after chemotherapy in malignant forms of gestational trophoblastic disease]

The authors reviewed the subsequent pregnancy experience in patients with malignant gestational trophoblastic disease who were managed at the Czechoslovak Trophoblastic Disease Center between January 1981 to December 1990. Thirty-five women who conceived following successful chemotherapy of gestational trophoblastic disease subsequently became pregnant a total of 53 times. Twenty-seven of these 53 pregnancies or 51% terminated in live-born infants. Major or minor congenital malformations were not detected. Those subsequent pregnancies concluded in 23 full-term deliveries (85%) and 4 premature births (15%). Primary cesarean section was performed for 5 (19%) women. Three or 6% ended in spontaneous abortion, one or 2% ended in mola hydatidosa partialis and mola hydatidosa completa. Sixteen pregnancies or 30% terminated in therapeutic abortion. Five women or 9% are now pregnant. Those patients who are treated successfully with chemotherapy should be reassured that they can anticipate a normal reproductive outcome in later conceptions.