Risk factors for recurrence in clinically early endometrial carcinoma: an analysis of 183 consecutive cases

This study includes 183 patients with clinical stage I endometrial carcinoma. All patients had standard surgical staging procedure including peritoneal cytology, total abdominal hysterectomy, bilateral pelvic and paraaortic lymphadenectomy. The factors analysed for recurrence were age, menopausal state, cell type, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, cervical involvement, microscopic vaginal metastases, adnexal metastases, peritoneal cytology, concomitant endometrial hyperplasia and pelvic and paraaortic node metastases. The overall recurrence rate was 14.2% (26/183). Of the 26 patients with recurrence, 11 had local and 13 had distant metastases. In the remaining two patients (7.7%), both local and pelvic metastases were observed. Of the factors analysed, age, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, microscopic vaginal metastases, adnexal involvement and pelvic and paraaortic nodal metastases were found to be significant predictors of recurrence. After multivariate analysis, advanced age (RR = 1.05), marked mitotic activity (RR = 3.11), pelvic and/or paraaortic nodal metastases (RR = 6.37) were chosen as the most important determinants of recurrence. In terms of surgical pathological stages, recurrence risk reaches up to 45.4% for stage IIIC disease. Using surgical pathological parameters, it is possible to predict recurrence but because of high rate of distant failures it still seems hard to improve survival of this group. Detection of a substantial risk of recurrence even in stage IA/B grade 1 group warrants adjuvant therapy in all patients after primary surgery.

Is routine appendectomy beneficial in the management of ovarian cancer?

A retrospective analysis of 136 patients with ovarian carcinoma subjected to appendectomy as a part of surgical procedure was carried out to assess the importance of appendectomy in patients with ovarian cancer. Of the 136 patients studied, 94 had epithelial and 38 had non-epithelial type of primary ovarian carcinoma. In the remaining 4 patients, the primary operation was performed with an intraoperative diagnosis of ovarian carcinoma but the final pathological examination revealed appendiceal carcinoma metastatic to ovaries. The overall appendiceal involvement in the study group with primary ovarian cancer was found to be 32.5% (43/132). This figure was 15.7% and 39.3% for non-epithelial and epithelial tumors, respectively. Involvement of the appendix ranged from 8.8% for patients with stage I disease to 46.0% for patients with stage III-IV disease. Four of the appendices found to be inflamed during the surgical explorations were later reported as acute appendicitis. The frequent occurrence of metastatic disease in the appendix in patients with ovarian cancer suggests routine appendectomy is appropriate for staging early cases and for contributing to maximal cytoreduction in advanced cases.

Correlation between clinical and histopathologic risk factors and lymph node metastases in early endometrial cancer (a multivariate analysis of 183 cases)

This study includes 183 patients with clinical stage I endometrial cancer subjected to peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy and omental biopsy during a 12-year period in a single institution. The factors analyzed were age, menopausal state, cell type, grade, mitotic activity, myometrial invasion, lymphovascular space invasion, cervical involvement, microscopic vaginal metastases, adnexal metastases, peritoneal cytology, presence of concomitant endometrial hyperplasia and lymph node status. The overall incidences of pelvic and para-aortic lymph node metastases were found to be 15.3% (28/183) and 9.3% (17/183), respectively. In five of 17 patients (29.4%) with para-aortic nodal metastases, pelvic nodes were free of tumor. The most significant prognostic factors for positive pelvic and/or para-aortic nodes were found to be the depth of myometrial invasion, grade of tumor and age.

Loss of heterozygosity at the bcl-2 gene locus and expression of bcl-2 in human gastric and colorectal carcinomas

The loss of heterozygosity (LOH) at the bcl-2 gene locus and the expression of the bcl-2 gene were examined in gastric and colorectal carcinoma cell lines and carcinoma tissues. LOH at the bcl-2 locus was detected in 24% (4/17) of gastric and 60% (6/10) of colonic carcinomas, all of which were well differentiated adenocarcinomas, whereas LOH was not seen in poorly differentiated ones. On the other hand, 24% (5/21) of poorly differentiated stomach cancers overexpressed bcl-2 gene, whereas no overexpression was detected in well differentiated stomach cancer. Three gastric and three colorectal carcinoma cell lines, all of which were derived from poorly differentiated adenocarcinomas, expressed considerable levels of bcl-2 mRNA and protein. These results suggest that LOH at the bcl-2 locus is frequently associated with well differentiated adenocarcinomas of the stomach and colon, and bcl-2 overexpression has implications for the development of poorly differentiated adenocarcinomas of the gastrointestinal tract.

Pregnancy outcome after hydatidiform mole, initial and recurrent

Pregnancy outcome after complete and partial hydatidiform mole was evaluated in 170 patients. Of the 170 patients, 143 became pregnant a total of 250 times. Patients with incomplete hydatidiform mole had 232 subsequent pregnancies that resulted in 169 (72.8%) term deliveries, 30 (12.9%) spontaneous abortions, 7 (3.0%) induced abortions, 6 (2.6%) stillbirths, 13 (5.6%) preterm deliveries, 6 (2.6%) recurrent moles and one (0.4%) ectopic pregnancy. Of the subsequent pregnancies in patients with partial hydatidiform mole, full-term delivery, spontaneous abortion and recurrent mole occurred in 10 (55.6%), 5 (27.8%) and 3 (16.7%) of the patients, respectively. Among the 9 patients with recurrent hydatidiform mole, viable term pregnancy was achieved in 4. Even patients with recurrent hydatidiform mole can be assured that they can have a normal subsequent pregnancy.

Trends in maternal mortality at a university hospital in Turkey

OBJECTIVE

To highlight recent trends in maternal mortality in Hacettepe University Hospital.

METHOD

A retrospective clinical analysis of 117 maternal deaths between 1968 and 1992.

RESULTS

The overall maternal mortality ratio was 180/100,000 (108/59,993). In terms of 5-year periods, the maternal mortality ratio declined from 417.7 in 1968-72 to 73.7 in 1988-92. Infection was the most common cause of death (59.8%), followed by cardiac disease (8.5%) and hemorrhage (8.5%). Infection related deaths were either due to septic abortion (75.7%) or puerperal sepsis (24.3%). While 73.9% of all deaths were due to infection in 1968-72, this figure contributed only 9.1% of the deaths in 1988-92. When infection, hemorrhage, cardiac disease ad toxemia are investigated together, percentages of their contribution varies from 95.7% in 1968-72 to 54.5% in 1988-92 period.

CONCLUSIONS

Maternal mortality ratios are decreasing significantly in our institution. An another promising finding is the further reduction in direct causes especially in recent years. However, an improvement in the care of pregnant women is necessary to continue this declining trend.

The influence of tocolytic therapy on serum digoxin-like immunoreactive substance concentration

Digoxin-like immunoreactive substance (DLIS) has been proposed to have a role in what seems to be the timely onset of labor. The relationship between the DLIS in patients with preterm labor and the success of tocolytic therapy with ritodrine and nifedipine has been studied. Using a commercially available radioimmunoassay kit, DLIS levels were determined in a total of 47 women with preterm labor and in 30 control. Tocolysis was successful in 37 of 47 women, in 20 of whom nifedipine and in 17 ritodrine was the tocolytic agent. Mean DLIS concentration was higher in patients with preterm labor. Moreover, DLIS levels were found to be decreased by successful tocolysis as could be observed from the values before initiation of tocolytic therapy and on the 3rd day of tocolysis for both nifedipine (0.268 +/- 0.198 vs. 0.220 +/- 0.210 ng/ml) and ritodrine (0.250 +/- 0.176 vs. 0.196 +/- 0.147 ng/ml; Wilcoxon test, p < 0.05).

Reduced expression of nm23 protein is associated with advanced tumor stage and distant metastases in human colorectal carcinomas

The nm23 gene, which encodes nucleoside diphosphate (NDP) kinase, is proposed as a metastatic suppressor gene. Loss of heterozygosity (LOH), and the expression of the nm23 gene were examined on matched sets of primary tumors and lymph node as well as distant metastases from colorectal carcinomas. Three (15%) of the 20 informative specimens examined showed LOH for the nm23 locus. nm23 was expressed in all the carcinomas as well as in nonneoplastic colonic mucosa at the mRNA and protein levels. Most of the carcinomas expressed the nm23 transcript at higher levels than the corresponding nonneoplastic colonic mucosa. By Western blotting, the level of nm23 protein expression in the tumors showed an inverse correlation with the tumor stage. Furthermore, distant metastatic tumors in the liver and lung showed reduced nm23 immunoreactivity in comparison with their primary tumor, although nm23 immunoreactivity was the same in the primary tumors and in local lymph node metastases. These results suggest that decreased nm23 expression may be associated with distant metastatic spread.

Postconceptional cervical cerclage

OBJECTIVE

To determine the outcome and morbidity of pregnancies following cervical cerclage.

METHOD

Records were reviewed for 326 patients with 374 singleton pregnancies between 1980 and 1990.

RESULT

McDonald and Shirodkar procedures were carried out in 323 and 51 pregnancies, respectively. The procedure was classified as elective if based on past history (n = 330). In 44 pregnancies, cervical dilatation prompted operation. The overall fetal survival rate has increased from 17.7% to 79.1% after cervical cerclage. While the presence of cervical dilatation at suture placement had a prognostic value, the surgical technique, gestational age at suture placement and progestin therapy had no significant effect on survival. Premature rupture of membranes and chorioamnionitis were found to be the leading causes of morbidity.

CONCLUSION

Cervical cerclage seems to the treatment of choice in patients with cervical incompetence. Only the presence of cervical dilatation at operation was found to have a prognostic value among the factors analyzed.

Struma ovarii

OBJECTIVE

To review the clinicopathological experience of patients with benign and malignant struma ovarii.

METHOD

A retrospective institutional analysis of 2 patients with malignant and 14 patients with benign struma ovarii, treated during a period of 20 years.

RESULT

The patients with struma ovarii constituted 1.0% of all ovarian neoplasms in our institution (16/1501). Four percent of the germ cell tumors were calculated to be of struma ovarii (16/382). The stages of the malignant cases were recorded as 1A and 1C. Besides detection at early stage, a biologically low grade tumor was encountered as well. Although 5 of the patients had goitre, none of them had hyperthyroidism. None of the patients had a bilateral tumor. However, in 2 patients, a serous cystadenoma and dermoid cyst were found in the contralateral ovaries. The preoperative and intraoperative diagnosis of malignant struma ovarii proved to be difficult since 2 patients subjected to radical surgery according to suspicious frozen section reports in this series later were found to be benign struma ovarii.

CONCLUSION

The low metastatic potential and slow progression rate of malignant struma ovarii support conservative surgery especially in young patients who have not yet completed their families.

Expression of amphiregulin, a novel gene of the epidermal growth factor family, in human gastric carcinomas

The expression of mRNA for amphiregulin (AR), a novel gene of the epidermal growth factor family, was examined in 8 human gastric carcinoma cell lines and 32 gastric carcinoma tissues as well as corresponding normal mucosa. Of the 8 gastric carcinoma cell lines, 7 expressed 1.4 kb AR mRNA at various levels. The expression of AR mRNA by TMK-1 and MKN-28 cells was increased by treatment with epidermal growth factor or transforming growth factor a. In surgical cases, all the gastric carcinoma tissues and their adjacent normal mucosa expressed AR mRNA. Interestingly, 20 (62.5%) out of 32 tumors expressed AR mRNA at higher levels than their corresponding normal mucosas (tumor/normal > or = 1.2). No obvious correlation was observed between the AR mRNA levels and the histological types or tumor staging of gastric carcinoma. Immunohistochemically, AR protein was localized to the cytoplasm and/or nucleus in tumor cells. These results suggest that AR produced by tumor cells may be involved in the pathogenesis and/or progression of human gastric carcinoma.

Increased expression of p34cdc2 and its kinase activity in human gastric and colonic carcinomas

We examined the expression of p34cdc2 and its kinase activity in human gastric and colonic carcinoma cell lines and carcinoma tissues and studied its relation with a tumor-suppressor gene product, p53. All the gastric and colonic cancer cell lines expressed p34cdc2 and showed its kinase activity at various levels. When the cells were arrested in mitotic metaphase by the use of nocodazole, p34cdc2 kinase activity was induced and p53 was apparently phosphorylated. Of 12 gastric carcinoma cases, 11 (91.7%) showed higher p34cdc2 kinase activity in tumor tissues than in corresponding non-neoplastic mucosa. The protein kinase activities in the individual cases were well correlated with the levels of p34cdc2 protein expression. A good correlation was also found between the expression of p34cdc2 and proliferating cell nuclear antigen (PCNA). Almost all the colonic carcinomas showed higher cdc2 kinase activity and increased p34 expression when compared with non-neoplastic mucosa. Interestingly, most of the gastric and colonic carcinomas having high cdc2 kinase activity expressed high levels of p53. These findings suggest that the increased p34cdc2 kinase activity might cause the development and proliferation of gastric and colonic carcinomas, partly through abnormal p53 accumulation.

Risk factors for groin node metastasis in squamous carcinoma of the vulva: a multivariate analysis of 39 cases

This study includes 39 patients with squamous carcinoma of the vulva subjected to radical surgery. Stage, tumor description, cell type, lesion localization, lesion size, depth of invasion, grade, lymphovascular space invasion, number of mitoses, degree of stromal inflammatory reaction, and tumors in surgical margins were analyzed for groin metastasis. Of the factors analyzed, stage (P = 0.018), grade (P = 0.007) and depth of invasion (P = 0.001) were found to be the most important predictors of node metastasis. While a combination of factors permitted to define a low-risk group with 0% node metastasis, it seems hard to identify preoperatively those patients with no risk of nodal metastasis.

Activated protein C levels in patients with gynecologic tumors

Activated protein C (APC) levels were measured in the plasma of patients with benign and malignant gynecologic tumors preoperatively, and on postoperative days 1 and 7. Preoperative levels of APC were found to be significantly low in both groups of patients compared to a group of healthy subjects. On postoperative day 1, levels of APC decreased significantly in both groups of patients compared to preoperative levels. By the 7th postoperative day, levels of APC in patients with benign tumors had increased significantly compared to postoperative day 1; levels in patients with malignant tumors, however, remained low. Our findings imply that there is a substantive correlation between gynecologic tumors, gynecologic surgery and the coagulation inhibitor, APC, which, in turn, can presumably be used to identify gynecologic patients who are at high risk for venous thrombosis.

Complications of radical vulvectomy and inguinal lymphadenectomy for the treatment of carcinoma of the vulva

Forty-two patients with invasive carcinoma of the vulva, subjected to radical vulvectomy and inguinal lymphadenectomy, were evaluated retrospectively. The mean age of patients was 61.6 years. Fifteen patients (35.7%) had complicating medical diseases, the histopathological diagnoses were squamous carcinoma (n = 39), undifferentiated carcinoma (n = 1), and malignant melanoma (n = 2). The postoperative morbidity and mortality rates were found to be 73.8% and 11.6%, respectively.

Expression of transforming growth factor alpha in human tissues: immunohistochemical study and northern blot analysis

The expression of transforming growth factor alpha (TGF-alpha) was examined in various human tissues and the fetus, using immunohistochemistry and Northern blot analysis. TGF-alpha immunoreactivity was detected mainly in the epithelial cells of the digestive tract, liver, pancreas, kidney, thyroid, adrenal, skin, mammary gland and genital organs. In the digestive tract, epithelial cells with regenerative change or hyperplastic change showed strong immunoreactivity to TGF-alpha. Peripheral nerve, vessels, megakaryocytes and macrophages in the lung and spleen were also positive for TGF-alpha. By Northern blot analysis the expression of TGF-alpha mRNA was confirmed in the digestive tract, salivary gland, thyroid, kidney and mammary gland. In the human fetus, the nerve tissues, liver, adrenal and kidney were positive for TGF-alpha. Strong immunoreactivity to TGF-alpha was observed in the hepatocytes of the fetus. These findings indicate that TGF-alpha is produced by a variety of non-neoplastic cells in both adult and fetal tissues.

A non-antibiotic antimicrobial mixture (C31G): evaluation of the antimicrobial efficiency of C31G on vaginal cultures

Minimum inhibitory concentrations and the effective period for cidal concentrations of an amphoteric surfactant mixture (C31G) were determined on 13 microorganisms (common bacteria, strains ATCC, and fungi) by microtiter dilution procedure. Also the antimicrobial efficiency of this composition (C31G) was evaluated on 105 culture samples which were obtained from (Turkish) patients having vaginal infections. E. coli was found to be the most frequently observed microorganism (45.45%) in these samples and C31G was determined to be active on microorganisms obtained from vagina at low concentrations in a short time.

Synchronous primary malignancies of the female genital tract

This study includes 29 patients with synchronous primary malignancies of the female genital tract. These patients constituted 1.7% of all genital malignancies. The most frequently observed synchronous neoplasms were those of the ovary together with the endometrium (51.7%). Most patients had early-stage and low-grade disease. Stage I disease was observed in 68.1% of patients with ovarian cancer. Patients with synchronous ovarian and endometrial cancer had a 73.3% 5-year survival rate, suggesting a favorable prognosis.

Reproductive performance after conventional metroplasty: an evaluation of 102 cases

OBJECTIVE

To evaluate the influence of conventional metroplasty on reproductive performance of symmetric uterine anomalies and determine the complications of these procedures.

DESIGN

A retrospective clinical analysis of consequently operated 102 women.

SETTING

Institutional.

PATIENTS AND PARTICIPANTS

One hundred two patients with bicornuate and septate uterus and a history of late recurrent abortion and/or preterm delivery were included in this study.

INTERVENTIONS

Jones, Strassman, and Tompkins procedures for metroplasty and McDonald operation for cervical cerclage.

MAIN OUTCOME MEASURE

The fetal survival rate has increased from 3.7% before operation to 75.0% afterwards. In only two patients uterine rupture was observed.

RESULTS

Conventional metroplasty improves the fetal survival rate in women with symmetric uterine anomalies.

CONCLUSIONS

Our results confirm the view that conventional metroplasty seems to be an operation of choice in women with symmetric uterine anomalies and a history of recurrent late abortion and preterm delivery. However, uterine rupture and postoperative infertility may be potential complications.

Prognostic value of mitotic activity, eosinophilic and inflammatory reaction in stage I cancer of the uterine cervix

This study includes 110 patients treated surgically for stage I squamous cell carcinoma of the cervix. The prognostic significances of mitotic activity, stromal inflammatory and eosinophilic reactions were studied. The 5-year survival rate varied from 75.0% to 93.3% and pelvic lymph node metastases (PLNM) varied from 23.0% to 31.2% according to degree of these variables. None of these pathological parameters was found to be a significant predictor of pelvic lymph node metastases and 5-year survival.

Remission rates and significance of prognostic factors in gestational trophoblastic tumors

The clinical courses of 82 women with gestational trophoblastic tumors were evaluated in accordance with International Federation of Gynecologists and Obstetricians staging, traditional criteria and the modified World Health Organization prognostic scoring system. The overall remission rate was 79.3% (65/82), and the mortality rate was 20.7% (17/82). All the patients with nonmetastatic stage I disease and all with prognostic scores less than or equal to 4 attained remission, whereas patients at high risk and with stage IV disease had the lowest remission and survival rates. The results support the validity of each system. However, the World Health Organization scoring system, a combination of traditional criteria and International Federation of Gynecologists and Obstetricians staging seemed to be the most reliable for predicting treatment failures.

Management of invasive cervical cancer in patients initially treated by simple hysterectomy

This study includes 15 patients with invasive cervical cancer found at the time of standard hysterectomy for benign conditions. All patients underwent laparotomy and were subjected to peritoneal cytology, radical parametriectomy, bilateral pelvic and para-aortic lymphadenectomy. Residual disease was found in 10 of the 15 patients (66.7%). The 3-year survival of patients with and without residual disease were 80% and 100%, respectively. Following secondary radical surgery, five patients without evidence of residual disease were identified and spared the risks of radiation therapy. Furthermore, two patients with para-aortic lymph node metastases, who would otherwise have been overlooked, were thus treated completely. One patient died of complications of secondary surgical procedure.

p53 point mutations in primary human gastric carcinomas

p53 point mutations in primary gastric carcinomas were analyzed by performing cDNA deoxynucleotide sequencing of the gene. Out of 16, 9 (56.3%) primary gastric carcinoma cases, including early cancer, showed one or more p53 point mutations in their open-reading frame, and 4 out of 9 cases had a p53 point mutation within highly conserved domains. The characteristics of the p53 mutation spectrum observed in primary tumors were (a) frequent mutation at an A:T pair (50%, 7 out of 14 mutations), (b) high transversion incidence (29%, 4 out of 14 mutations), (c) no transition at CpG, and (d) no G:C to T:A transversion. Our results suggest that p53 mutation is a common event in gastric carcinoma occurring from the early stage of progression with its specific mutation spectrum.

Tyrosine kinase activity of epidermal growth factor receptor in human gastric carcinomas

We examined tyrosine kinase activity of epidermal growth factor (EGF) receptor in a total of 34 human gastric carcinomas as well as in non-neoplastic gastric mucosa from the same patients. EGF receptor kinase activity of the carcinoma tissues and the non-neoplastic mucosa were 1.28 +/- 1.00 (Mean +/- S.E.) and 0.16 +/- 0.04 respectively, if the EGF receptor kinase activity of human placenta is 10. Twenty-one (62%) carcinoma tissues showed higher EGF receptor kinase activity than corresponding non-neoplastic mucosa, while in 6 cases (18%) the kinase activity was higher in the non-neoplastic mucosa than in the tumor tissues. No obvious correlation was observed between the increased kinase activity in the tumors and histological type or tumor staging. One tumor showed extremely high receptor kinase activity with ERBB gene amplification. This tumor showed strong immunoreactivity to EGF itself.