Anatomic Subtype Differences in Extramammary Paget Disease: A Meta-Analysis

Importance

Extramammary Paget disease (EMPD) is a rare, highly recurrent cutaneous malignant neoplasm of unclear origin. EMPD arises most commonly on the vulvar and penoscrotal skin. It is not presently known how anatomic subtype of EMPD affects disease presentation and management.

Objective

To compare demographic and tumor characteristics and treatment approaches for different EMPD subtypes. Recommendations for diagnosis and treatment are presented.

Data Sources

MEDLINE, Embase, Web of Science Core Collection, and Cochrane Reviews CENTRAL from December 1, 1990, to October 24, 2022.

Study Selection

Articles were excluded if they were not in English, reported fewer than 3 patients, did not specify information by anatomic subtype, or contained no case-level data. Metastatic cases on presentation were also excluded.

Data Extraction and Synthesis

Abstracts of 1295 eligible articles were independently reviewed by 5 coauthors, and 135 articles retained. Reporting was in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The analysis was cunducted in August 2019 and updated in November 2022.

Findings

Most vulvar EMPD cases were asymptomatic, and diagnosis was relatively delayed (mean, 25.1 months). Although most vulvar EMPD cases were intraepidermal (1247/1773 [70.3%]), radical surgeries were still performed in almost one-third of cases. Despite this aggressive surgical approach, 481 of 1423 (34%) recurred, commonly confined to the skin and mucosa (177/198 [89.4%]). By contrast, 152 of 1101 penoscrotal EMPD cases (14%) recurred, but more than one-third of these recurrences were regional or associated with distant metastases (54 of 152 [35.5%]). Perianal EMPD cases recurred in one-third of cases (74/218 [33.9%]), with one-third of these recurrences being regional or associated with distant metastasis (20 of 74 [27.0%]). Perianal EMPD also had the highest rate of invasive disease (50% of cases).

Conclusions and Relevance

The diagnosis and treatment of EMPD should differ based on anatomic subtypes. Considerations for updated practice may include less morbid treatments for vulvar EMPD, which is primarily epidermal, and close surveillance for local recurrence in vulvar EMPD and metastatic recurrence in perianal EMPD. Recurrences in penoscrotal subtype were less common, and selective surveillance in this subtype may be considered. Limitations of this study include the lack of replication cohorts and the exclusion of studies that did not stratify outcomes by anatomic subtype.

Evidence-Based Clinical Practice Guidelines for Extramammary Paget Disease

IMPORTANCE

Extramammary Paget disease (EMPD) is a frequently recurring malignant neoplasm with metastatic potential that presents in older adults on the genital, perianal, and axillary skin. Extramammary Paget disease can precede or occur along with internal malignant neoplasms.

OBJECTIVE

To develop recommendations for the care of adults with EMPD.

EVIDENCE REVIEW

A systematic review of the literature on EMPD from January 1990 to September 18, 2019, was conducted using MEDLINE, Embase, Web of Science Core Collection, and Cochrane Libraries. Analysis included 483 studies. A multidisciplinary expert panel evaluation of the findings led to the development of clinical care recommendations for EMPD.

FINDINGS

The key findings were as follows: (1) Multiple skin biopsies, including those of any nodular areas, are critical for diagnosis. (2) Malignant neoplasm screening appropriate for age and anatomical site should be performed at baseline to distinguish between primary and secondary EMPD. (3) Routine use of sentinel lymph node biopsy or lymph node dissection is not recommended. (4) For intraepidermal EMPD, surgical and nonsurgical treatments may be used depending on patient and tumor characteristics, although cure rates may be superior with surgical approaches. For invasive EMPD, surgical resection with curative intent is preferred. (5) Patients with unresectable intraepidermal EMPD or patients who are medically unable to undergo surgery may receive nonsurgical treatments, including radiotherapy, imiquimod, photodynamic therapy, carbon dioxide laser therapy, or other modalities. (6) Distant metastatic disease may be treated with chemotherapy or individualized targeted approaches. (7) Close follow-up to monitor for recurrence is recommended for at least the first 5 years.

CONCLUSIONS AND RELEVANCE

Clinical practice guidelines for EMPD provide guidance regarding recommended diagnostic approaches, differentiation between invasive and noninvasive disease, and use of surgical vs nonsurgical treatments. Prospective registries may further improve our understanding of the natural history of the disease in primary vs secondary EMPD, clarify features of high-risk tumors, and identify superior management approaches.

Management of Lichen Sclerosus and Intraepithelial Neoplasia of the Vulva in the UK

Women with vulval intraepithelial neoplasia (VIN), lichen sclerosus (LS) and Paget's disease are referred either to gynaecologists or to dermatologists. We have ascertained the caseloads, referral patterns and treatment modalities used in the two specialties.

A postal questionnaire was sent to 540 consultant gynaecologists and 225 consultant and senior registrar members of the British Association of Dermatologists. 350 gynaecologists and 161 dermatologists returned completed questionnaires. The workload of LS and Paget's disease was evenly distributed, with 54% of dermatologists and 58% of gynaecologists seeing more than six cases of LS per annum and less than 1% seeing more than five cases of Paget's disease. 92% of responding gynaecologists saw at least one case of VIN per year whereas 43% of dermatologists saw no cases. Patients with VIN and Paget's were referred to gynaecologists for treatment by 66% of dermatologists. Both groups are equally prepared to treat LS. Indications for treatment of VIN and LS were suspicion of invasion and symptoms. Local excision of VIN is the treatment of choice by both gynaecologists and dermatologists. LS is predominantly treated with topical steroids but gynaecologists also use topical oestrogen and testosterone.

The great majority of responders favoured establishing a national register to study the outcome of vulval lesions.

The management of Paget's disease of the vulva*

Paget's disease of the vulva is an uncommon lesion, and gynaecologists and dermatologists generally have limited experience in its management. The British Society for the Study of Vulval Disease has established a register of cases, and we present a review of 76 cases registered to date. The majority of patients were treated by surgical excision and reconstruction, but non-surgical therapies are an option. Recent literature is reviewed to allow comparison.

Ovulation-stimulation drugs and cancer risks: a long-term follow-up of a British cohort

To assess long-term health effects of ovarian-stimulation drugs we followed-up for over 20 years a British cohort of 7355 women with ovulatory disorders, 43% of whom were prescribed ovarian-stimulation drugs, and identified a total of 274 deaths and 367 incident cancers. Relative to the general population, the cohort experienced lower mortality from most causes, including from all neoplasms combined, and lower incidence of cervical cancer, but higher incidence of cancers of the breast (relative risk: 1.13; 95% CI 0.97, 1.30) and corpus uteri (2.02; 1.37, 2.87). There were, however, no significant differences in the risk of cancers of the breast, corpus uteri, ovary, or of any other site, between women who had been prescribed ovarian-stimulation drugs and those who had not. Further analyses by type of drug and dose revealed a dose-response gradient in the risk of cancer of the corpus uteri (P for linear trend=0.03), with women given >or=2250 mg of clomiphene having a 2.6-fold (2.62; 0.94, 6.82) increase in risk relative to those who were not treated. These findings do not support strong associations between ovulation-stimulation drugs and cancer risks, but they indicate the need for continued monitoring to establish whether risks are elevated in certain subgroups of users.

Reduced E-cadherin expression correlates with disease progression in Paget's disease of the vulva but not Paget's disease of the breast

The growth and metastasis of many cancers is due in part to loss of cell-cell adhesion. E-cadherin, plakoglobin and beta-catenin are important in cell adhesion. Our aim was to examine the presence of these molecules in Paget's disease of the vulva and Paget's disease of the breast, and to correlate any differences in their expression with the presence of invasive disease or an underlying carcinoma. Sixty-three archival cases of Paget's disease of the vulva, including eight associated with invasive disease, and 23 archival cases of Paget's disease of breast, which included 10 cases with ductal carcinoma in situ alone, four cases with both ductal carcinoma in situ and invasive carcinoma, and five cases with underlying invasive carcinoma alone, were analysed immunohistochemically for expression of E-cadherin, plakoglobin and beta-catenin proteins. The respective mRNAs were also detected by in situ hybridisation using digoxigenin-labelled cRNA probes. Seventy-six percent (41/54) of Paget's disease of vulva cases had >50% of Paget cells expressing the E-cadherin protein, compared with 28 % (2/7) of Paget's disease vulva with invasive disease. This result was significant, with a P-value of 0.039. Twenty-five percent (14/55) of the intraepidermal Paget's disease of the vulva cases had >50% of Paget cells expressing the plakoglobin protein, compared with 12% (1/8) of cases of Paget's disease of vulva with invasive disease, and for beta-catenin, 9% (5/55) of the non-invasive Paget's disease of the vulva had >50% of Paget cells expressing beta-catenin, compared with 12% (1/8) of Paget's disease of the vulva cases with invasive disease. Sixty-five percent (15/23) of the Paget's disease of the breast had >50% of Paget cells expressing E-cadherin, and for plakoglobin and beta-catenin it was 17% (4/23) and 28% (6/21), respectively. The results were not significant. The results suggest that reduced expression of E-cadherin may have a role to play in the pathogenesis of invasive Paget's disease of the vulva. Abnormal plakoglobin expression may be involved in the formation of some cases of Paget's of the vulva and the breast.

Guidelines for the follow-up of women with vulvar lichen sclerosus in specialist clinics

It is recommended that women with vulvar lichen sclerosus be followed in specialist clinics where difficulty exists with symptom control or where there is clinical evidence of localized skin thickening. Follow-up is also recommended for women who have previously been treated for squamous cell carcinoma of the vulva (arising in lichen sclerosus or vulvar intraepithelial neoplasia) or where the pathologist expresses concern and is unable to make a definitive diagnosis of differentiated vulvar intraepithelial neoplasia.

Is localized, provoked vulvodynia an inflammatory condition?

OBJECTIVE

To perform a pilot study to investigate the relationship between localized, provoked vulvodynia of the vestibule and inflammatory cytokine expression.

STUDY DESIGN

Women with a diagnosis of localized, provoked vulvodynia had tissue samples taken for vulvar expression of Interleukin 1alpha and 1beta and tumor necrosis factor alpha and compared to those of a control group.

RESULTS

The study group did not show a significant increase in expression of inflammatory markers.

CONCLUSION

There was no evidence in this study that localized, provoked vulvodynia is an inflammatory condition, as previously thought. This may be helpful in explaining why some women are resistant to medical or antiinflammatory treatment and may allow treatment to be prescribed more effectively.

Acetowhite epithelium

OBJECTIVE

The study was undertaken to provide further understanding of the phenomenon of "acetowhite epithelium".

METHODS

Solutions of acetic and similar acids were applied to the atypical transformation zone to demonstrate (or not) acetowhite epithelium.

RESULTS

Acetowhite epithelium is not unique to acetic acid, but can be mimicked by other water soluble carboxylic acids.

CONCLUSIONS

Acetowhite epithelium is probably due to the reflection of light from the superficial layers of epithelium when they become opaque following the rapid penetration of these non-coagulant fixatives and their effect on nucleoprotein.

TP53 mutations in vulval lichen sclerosus adjacent to squamous cell carcinoma of the vulva

Non-neoplastic epithelial lesions of the vulva (NNEDV) lichen sclerosus (LS) and squamous hyperplasia (SH) have been implicated in the pathogenesis of squamous cell carcinoma of the vulva (SCC). To date, there have been no recognisable precursor lesions for SCC associated with NNEDV. TP53 is the most frequent genetic change in human cancers and can indicate both aetiology and molecular pathogenesis of tumours. A total of 27 SCC patients underwent immunohistochemistry (IHC) and TP53 mutational analysis using microdissection and direct sequencing. There were 19 patients with areas of adjacent epidermis: 17 had NNEDV (four SCCs had more than one adjacent lesion) and two had normal epidermis. In all, 70.4% of the SCCs, 40% LS and 22.2% SH demonstrated overexpression of p53. In total, 77.8% of SCCs, 46.7% of LS and 22.2% SH demonstrated mutations in TP53, with the majority of lesions having a mutation in codon 136. Eight cases were identified where the same mutation was identified in the SCC and in the adjacent area. These data suggest that TP53 mutations develop in NNEDV and are intrinsic to the clonal evolution that leads to SCC. The type of mutation detected is more likely to occur due to endogenous cellular changes rather than exogenous carcinogen exposure.

Cell cycle and apoptotic proteins in relation to ovarian epithelial morphology

OBJECTIVE

To assess the relationship between the expression of cell cycle and apoptotic proteins and the morphological appearance of the surface epithelium in non-neoplastic ovaries.

METHODS

The subjects for this study were 79 women who had undergone oophorectomy for benign conditions at the North Middlesex Hospital, London, and Royal Free Hospital, London, and whose ovaries had been reported on routine histology as entirely normal or containing physiological cysts or endometriosis. The epithelial morphology was reassessed on haematoxylin and eosin-stained paraffin wax sections using nine cytological and architectural parameters associated with premalignant intraepithelial changes. A 'score' was obtained for each ovary. Expression of p53, Ki67, cyclin D1 and Bcl-2 in the surface, cystic and endometriotic epithelium was assessed in corresponding sections using standard immunohistochemistry.

RESULTS

The median score for the morphological changes was significantly higher in the sections, which expressed p53 compared to those which did not. This difference remained significant in a subanalysis of the sections, which did not contain endometriosis. No relationship was identified between the morphological score and the expression of Ki67, Bcl-2 and cyclin D1.

CONCLUSION

Increased intraepithelial abnormality as assessed by an epithelial morphological score of ovarian sections is associated with expression of the p53 cell cycle protein. This lends credence to the hypothesis that the ovarian surface or cystic epithelium goes through an identifiable precursor or "premalignant" phase before the development of invasive disease. Further work is required to characterise the changes that take place before the development of malignancy in ovarian epithelium.

Vulvodynia

PURPOSE OF REVIEW

An increasing number of patients present with symptoms of vulvar pain, soreness, burning or irritation, which become chronic. Clinicians are often uncertain of the diagnosis. Terminology and an understanding of aetiology and therapy are evolving.

RECENT FINDINGS

Previous descriptions of vulvodynia have grouped patients according to whether pain is provoked by coitus (vulvar vestibulitis syndrome) or generalized and neuropathic pain (dysesthetic vulvodynia). Recent terminology debates have questioned whether 'vulvodynia' should be replaced by 'dysesthesia' and the term 'vestibulitis' avoided. Definitions of pain provocation, quality, duration, and distribution vary. Prevalence studies suggest one in six women may experience vulvodynia, although such a figure reflects clinic, patient or author reporting bias. Symptoms are as likely to be found in non-white as in white women. Although infection is often blamed, evidence for its role or that of inflammation is minimal. Immunohistochemistry has shown altered density of nerve endings and oestrogen receptors. There may be overlap with other pain syndromes. Several reviews have examined the many therapies available. Pharmacological alteration of nerve conduction (tricyclic antidepressants, gabapentin, local anaesthetics), biofeedback and sometimes surgery are helpful, but not always. Counselling and an understanding between patient and clinician/therapist are important for long-term results.

SUMMARY

Gynaecologists should be aware that they will encounter patients with vulvodynia who will need assessment and management. There are increasing numbers of clinics or clinicians with expertise to whom these patients can be referred.

Estrogen receptor expression in vulvar vestibulitis syndrome

OBJECTIVE

A pilot study was performed to investigate the relationship between vulvar vestibulitis syndrome and estrogen receptor expression.

STUDY DESIGN

Women with a diagnosis of vulvar vestibulitis syndrome had tissue samples taken for vulvar estrogen receptor-alpha expression and this was compared with a control group.

RESULTS

The study group showed a significant decrease in estrogen receptor expression, and 50% of the samples did not exhibit any receptor expression.

CONCLUSION

There appears to be a subgroup of women with vulvar vestibulitis syndrome who exhibit abnormal estrogen receptor-alpha expression. This may be helpful in explaining why some women are resistant to medical treatment and may allow treatment to be prescribed more effectively.

The role of angiogenesis in vulvar cancer, vulvar intraepithelial neoplasia, and vulvar lichen sclerosus as determined by microvessel density analysis

OBJECTIVES

We compared microvessel density (MVD) in normal, benign, preneoplastic, and neoplastic (squamous cell carcinoma (SCC)) vulvar disease to ascertain if this parameter could identify cases with lichen sclerosus (LS) and high-grade vulvar intraepithelial neoplasia (VIN3) at risk of developing malignancy.

METHODS

Microvessels were immunohistochemically stained in paraffin wax-embedded vulvar tissue sections with anti-von Willebrand factor (vWF) antibody using the streptavidin-biotin-horseradish peroxidase complex technique. Three "hot spots" with the greatest MVD were identified within 200 microm of the subepithelial dermis under low magnification (x 40 and x 100). The highest (HVD) and average (AVD) MVDs were quantified for each sample under high magnification (x 200) using an image analysis system.

RESULTS

HVD and AVD showed similar significant differences. SCC had significantly the highest MVD followed by VIN3, normal vulva, and LS. LS had significantly the lowest MVD, even lower than that of normal vulva. Two cases of VIN3 had much higher HVD (9.16 and 9.61) and AVD (6.89 and 7.71) compared with the main cluster of cases.

CONCLUSION

In vulvar LS, MVD, as assessed by HVD/AVD, is not a useful parameter in determining potential malignant progression, while in VIN3 this parameter could be valuable in identifying cases at greatest risk of progression to invasive disease.

Is there a link between vulval cancer and blood group?

Risk factors for squamous cell vulval cancer (SCC) remain unclear though there have been associations with lichen sclerosis, smoking, and vulval intraepithelial neoplasia (VIN). We studied 191 patients who had been referred to the vulval clinic at the Royal Free Hospital and who had both blood group and histopathology results available. Seventy-two percent of patients with SCC and non-neoplastic epithelial disorders of the vulva (NNEDV) were found to be in blood group A with only 17% in blood group O. Those with SCC associated with VIN had only 30% in blood group A with 50% in blood group O. The control population showed that 38% of the population were in blood group A and 43% were in blood group O. Our results suggest that blood group A is prevalent in patients with SCC associated with NNEDV but not in those women with squamous vulval cancer and associated VIN.

The effect of topical corticosteroids on Ki67 and p53 expression in vulval lichen sclerosus

BACKGROUND

Topical corticosteroids have become the treatment of choice for genital lichen sclerosus (LS) and are believed to be required for long-term relief of symptoms.

OBJECTIVE

To compare vulval LS that had been treated with topical corticosteroids, vulval LS that had not received topical corticosteroids, and histologically normal vulval skin.

METHODS

We used immunohistochemistry to look for Ki67 expression and abnormal p53 expression.

RESULTS

We found a statistically significant difference for p53 overexpression, with increased levels seen when comparing corticosteroid-treated LS with normal genital skin (P = 0.011). Ki67 expression was also significantly higher in the corticosteroid-treated group compared with normal genital skin (P = 0.001), and increased levels were also found in the treated group compared with untreated LS (P = 0.05).

CONCLUSIONS

Our data suggest that topical corticosteroids have an effect on cell cycle proteins in genital skin and, in particular, genital skin with LS changes.

The role of p53 and Ki67 in Paget's disease of the vulva and the breast

OBJECTIVE

Paget's disease of the vulva (PDV) and Paget's disease of the breast (PDB) are uncommon diseases, accounting for approximately 1% of all vulval neoplasms and 0.5-4% of all breast cancers, respectively. In 10-30% of vulval cases an invasive adenocarcinoma is present. In such cases the disease is often aggressive and recurrence rate is high. This is in contrast to PDB where the general consensus is that almost all cases are associated with an in situ or invasive ductal carcinoma. Our aim was to examine the presence of the tumor suppressor protein p53 and the proliferation marker Ki67 in PDV and PDB and correlate any differences in the expression of these two proteins with the presence of an underlying carcinoma.

METHODS

Immunohistochemistry was performed on 52 archival cases of PDV, which included 10 with associated invasive adenocarcinoma of the vulva, and on 37 archival cases of PDB, including 26 with available associated ductal carcinoma in situ (DCIS) or invasive carcinoma of the breast. All cases were formalin-fixed and paraffin wax-embedded. Monoclonal antibodies were used with microwave antigen retrieval. Streptavidin-biotin-horseradish peroxidase and 3,3'-diaminobenzidine detection methods were employed to visualize antibody binding and staining. A section was scored positive for p53 if more than 10% of cell nuclei were stained brown and Ki67 was expressed as a percentage of positive cells to the nearest 5% of cells showing nuclear positivity (Ki67 staining index).

RESULTS

p53 was expressed in 15 of 52 (29%) PDV cases and 5 of 37 (13%) cases of PDB. Four of the ten cases (40%) of PDV associated with invasive disease expressed p53 compared with 11 of 42 (26%) cases without invasive disease. The mean Ki67 staining index for PDV associated with invasion was 19%, and for that without invasion, 16%. In the breast cases, the mean staining index was 11%.

CONCLUSION

Our data suggest that p53 may have a role to play in PDV progression, and may be a late event in some cases, especially those associated with invasive disease. Ki67 has no apparent prognostic role in PDV as there was no significant difference between those cases associated with and those without invasive disease. Neither p53 nor Ki67 appears to have a prognostic role to play in PDB.

An unusual steroid-producing ovarian tumour: case report

The rapid onset of virilization in a post-menopausal woman is usually the result of androgen secretion from a tumour of adrenal or ovarian origin. Androgen secreting neoplasms of the ovary are rare and usually show autonomous secretion. Rarely, these may be driven by the high levels of gonadotrophins seen in the post-menopausal state. We describe the case of a 67-year-old woman with high serum testosterone and estradiol in association with the high gonadotrophin levels usually associated with the post-menopausal state. All hormonal parameters showed a significant suppression over 12 h with administration of the GnRH antagonist, cetrorelix. This observation implies that excess hormone synthesis was of ovarian origin and was gonadotrophin driven. Localization of the tumour was not possible by conventional ultrasound or computerized tomography scanning, but was achieved by venous sampling. Complete cure was achieved by total abdominal hysterectomy and bilateral salpingo-oophorectomy, with restoration of the endocrine profile to that expected for a post-menopausal woman. Rapidly acting GnRH antagonists, such as cetrorelix, offer a safe and useful diagnostic and therapeutic option in the management of ovarian steroid-secreting tumours, which show gonadotrophin dependency.

The role of vascular endothelial growth factor-A (VEGF-A) and platelet-derived endothelial cell growth factor/thymidine phosphorylase (PD-ECGF/TP) in Paget's disease of the vulva and breast

BACKGROUND

Paget's disease of the vulva and the breast are uncommon conditions. The pathogenesis underlying these diseases is still unclear. Vascular endothelial growth factor-A (VEGF-A), a potent angiogenic factor, has been demonstrated in a variety of tumour cell types and is thought to be involved in tumour expansion. Platelet-derived endothelial cell growth factor/thymidine phosphorylase (PD-ECGF/TP) has also been shown to stimulate angiogenesis.

MATERIALS AND METHODS

Fifty-four cases of Paget's disease of the vulva, including 10 with an associated invasive adenocarcinoma, and 38 cases of Paget's disease of the breast, including 26 with available associated ductal carcinoma in situ (DCIS) and/or invasive carcinoma of the breast, were evaluated immunohistochemically for the expression of VEGF-A and PD-ECGF/TP.

RESULTS

VEGF-A was not expressed in Paget's disease of the vulva or breast. PD-ECGF/TP was expressed in 22 out of 54 (41%) cases of Paget's disease of the vulva. Four of the cases associated with invasive disease (40%) expressed PD-ECGF/TP. Twenty-one out of 38 (55%) cases of Paget's disease of the breast were positive for PD-ECGF/TP.

CONCLUSION

Our data suggest that PD-ECGF/TP may have a role to play in the pathogenesis of Paget's disease of the vulva and the breast. The role of VEGF-A in Paget's disease of the vulva and the breast remains to be fully elucidated.

The clinical application of a dual head gamma camera with coincidence detection in 20 women with suspected ovarian cancer

OBJECTIVE

To assess the effectiveness of a dual head coincidence gamma camera in identifying ovarian cancer as a less expensive alternative to the traditional 2-[18F] fluoro-2-deoxy-D-glucose (18FDG) system using positron emission tomography.

DESIGN

Prospective study.

POPULATION

Twenty consecutive women suspected of having ovarian carcinoma. Inclusion was based on abnormal serum CA125 (reference range is 0-35 units/L), ultrasound, computerised tomography or clinical findings.

METHODS

Women underwent assessment before staging laparotomy. Two nuclear medicine physicians, who were blinded to the pre-operative assessment, reported on 18FDG- dual head coincidence gamma camera imaging.

MAIN OUTCOME MEASURES

The histology and operative staging were compared with the 18FDG- dual head coincidence gamma camera findings.

RESULTS

Twelve women had pelvic malignancies (nine primary and three recurrences), seven women had benign pathology and one patient had a borderline malignancy. We were able to image accurately all malignant pelvic masses with dual head coincidence gamma camera, as well as accurately demonstrate disease spread. Two of the benign pelvic masses localised 18FDG. The positive predictive value for detecting malignancy was 86%.

CONCLUSIONS

Dual head coincidence gamma camera offers accurate and affordable imaging in suspected ovarian masses, with improved specificity over CA125, ultrasound and computerised tomography. These results are similar to those obtained on more expensive dedicated PET systems. We report on a series of patients believed to have primary or recurrent carcinoma and recognise the need to include patients more likely to have benign lesions to assess false positive results. However, we believe that dual head coincidence gamma camera is useful in the pre-operative assessment of women with suspected ovarian cancer.

Ovarian epithelial dysplasia in relation to ovulation induction and nulliparity

OBJECTIVE

The goal of this study was to assess the relationship between ovulation induction, nulliparity, and ovarian epithelial dysplasia.

METHODS

This retrospective cohort study was performed in one teaching and one district general hospital in London. The subjects, 83 women who had undergone hysterectomy and bilateral oophorectomy and whose ovaries were reported as "normal," were divided into three groups: ovulation induction (13), nulliparity (20), and fertile controls (50). These ovaries were independently reviewed by two pathologists who assigned a score of 0, 1, or 2 to nine epithelial cytological and architectural features. The main outcome measure was the total dysplasia score, which was used to quantify the degree of ovarian epithelial abnormality in the three groups.

RESULTS

The mean dysplasia score was significantly higher in the women who had undergone ovulation induction than in the fertile controls (7.92 vs 5.70, P = 0.012). The magnitude of the difference between the ovulation induction group and controls remained similar after adjusting for age, parity, and duration of oral contraceptive use (2.17, 95% CI: -0.11-4.44). However, the statistical significance of this difference was reduced (P = 0.062). We did not find any evidence of a difference in dysplasia score between nulliparous women and controls, neither before (P = 0.85) nor after adjusting for age and duration of oral contraceptive use (P = 0.87).

CONCLUSIONS

These results suggest a possible association between ovarian epithelial dysplasia and ovulation induction therapy, in accord with previous reports of increased risk of ovarian cancer in women with a history of fertility treatment. The higher dysplasia score could be attributable to the drugs used to induce ovulation or to a genetic susceptibility to ovarian cancer.

Urinary tract infection in pregnancy

Urinary tract infection is one of the most frequently seen 'medical' complications in pregnancy. The pioneering work of Edward Kass discovered that 6% of pregnant women had asymptomatic bacteriuria associated with increased prematurity and perinatal mortality compared to women with sterile urine. Screening for bacteriuria in pregnancy has become routine. The prevalence of asymptomatic bacteriuria as well as the associated complications described by Kass in 1962 are higher compared to most data collected in the 1980s and late 1990s in different populations in various parts of the world. Other factors such as vaginal colonization have been recognized as important contributors to preterm labour. The value of screening for bacteriuria has to be re-addressed considering methods, significance and costs. Treatment of urinary tract infection in pregnancy is critically reviewed.

Cell cycle proteins as molecular markers of malignant change in vulvar lichen sclerosus

Lichen sclerosus (LS) has a known association with the development of squamous cell carcinoma of the vulva. The purpose of this study was to investigate molecular markers, which could indicate premalignant changes. Multiple sequential vulvar biopsies were taken over a period of 11 years from a patient with longstanding LS. Immunohistochemical staining was used to demonstrate a range of molecular markers. Increased expression of p53 and Ki67 was found in areas of squamous hyperplasia (SH) and differentiated vulvar intraepithelial neoplasia (dVIN) which correlated with the subsequent development of invasive squamous cell carcinoma (SCC). Molecular changes have been found to accompany histologic changes in the progression of vulvar LS to malignancy. Such markers may prove a useful addition in the clinical management of these conditions.

Role of angiogenesis in benign, premalignant and malignant vulvar lesions

OBJECTIVE

To investigate the presence of angiogenic factors in benign, premalignant and malignant vulvar lesions.

STUDY DESIGN

Immunohistochemical demonstration of vascular endothelial growth factor (VEGF) and platelet-derived endothelial cell growth factor (PD-ECGF) in normal vulvar skin, lichen sclerosus, vulvar intraepithelial neoplasia (VIN) and vulvar cancer.

RESULTS

VEGF was found in the majority of vulvar cancers but only a minority of VIN lesions. PD-ECGF was found in the majority of lesions.

CONCLUSION

Demonstration of angiogenesis may suggest which preinvasive lesions will progress to invasive cancer.

Assessment of condoms as probe covers for transvaginal sonography

PURPOSE

This prospective study assessed the incidence of transvaginal probe contamination and breakage of condoms used to cover those probes during transvaginal sonography.

METHODS

Over a 9-month period, 214 women underwent transvaginal sonography with probes that had been coated with gel and then covered with a latex condom. Condom defects were detected after the scans by inspection, by adding hydrogen peroxide, and by filling the condoms with 500 ml of water. After the condoms were removed, the probe was either wiped with a dry tissue (during the first 18 weeks of the study) or wiped first with a dry tissue and then with a 70% isopropyl alcohol wipe. Probe head contamination was assessed by periodic swab sampling and culturing for bacteria and herpes simplex virus. Samples of the sonographic gel also were tested for bacterial contamination at approximately weekly intervals.

RESULTS

A total of 217 condoms were used, 3 of which broke and were discarded while being applied to the probe. Two of the 214 condoms used (0.9%) were found upon visual inspection to have perforations. None of the other 212 condoms leaked upon being filled with water; none of the 204 condoms tested with hydrogen peroxide showed bubbles. Only 1 of the 46 probe swab samples was positive for bacteria (Acinetobacter species); none of the 26 probe swab samples cultured for viruses or the 25 gel samples cultured for bacteria were positive.

CONCLUSIONS

Condoms used to cover transvaginal probes showed a low rate of perforation. Disinfection of the probe with isopropyl alcohol wipes further reduced the risk of contamination.

Ovarian cancer and infertility: a genetic link?

A genetic mechanism may be responsible for the increased incidence of ovarian cancer in some infertile women (ie, those who failed to conceive despite treatment).

Assessment of response to treatment in vulvar vestibulitis syndrome by means of the vulvar algesiometer

OBJECTIVE

A pilot study was undertaken to investigate the utility of the vulvar algesiometer in correlating symptom improvement with treatment response.

STUDY DESIGN

Women with a diagnosis of vulvar vestibulitis syndrome attending a specialist vulvar clinic were assessed with the vulvar algesiometer before and after treatment.

RESULTS

The conditions of 25 patients had improved to the point of discharge, and readings from before and after treatment were compared. There was a statistically significant difference in the vulvar algesiometer readings before and after treatment and this improvement was reflected in patient response. Nine patients had no response to treatment and also no significant improvement in vulvar algesiometer score.

CONCLUSION

The vulvar algesiometer provides an easy noninvasive means of assessing vestibular tenderness in vulvar vestibulitis syndrome that is well tolerated by the patients and provides a degree of biofeedback for them.

An immunohistochemical study of androgen, oestrogen and progesterone receptors in the vulva and vagina

OBJECTIVE

To map potential sites of sex steroid action in the human vulva.

METHODS

Monoclonal antibodies to androgen, oestrogen and progesterone receptors were used to stain frozen sections of vulval skin, vagina and suprapubic skin. A scoring system was devised to compare receptor distribution in the epidermis and dermis of skin with vaginal epithelium and stroma.

RESULTS

Androgen receptors were seen in epidermal keratinocytes, sebaceous glands, sweat glands, hair follicles and dermal fibroblasts of skin, and epithelial cells and stromal fibroblasts of the vagina. Androgen receptor scores were significantly higher in the epidermis of labia majora and minora than in vaginal epithelium. Oestrogen receptors were seen in basal and suprabasal cells of vaginal epithelium and epidermis of labia minora but were restricted to basal keratinocytes in true skin. They were seen in stromal fibroblasts and vaginal smooth muscle, and dermal fibroblasts of the skin. Oestrogen receptors were highest in vaginal epithelium and stroma, and lowest in suprapubic skin. Progesterone receptors were seen in vaginal epithelium, fibroblasts and smooth muscle but not in the vulva. There was no evidence of significant differences in androgen or oestrogen receptor staining in the vulva of pre- or postmenopausal women.

CONCLUSION

The transition from vagina to vulva is marked by an increase in androgen and a decrease in oestrogen and progesterone receptors. This distribution of receptors would indicate a limited role for oestrogen creams on the vulva.

Prediction of radiotherapy response of cervical carcinoma through measurement of proliferation rate

Estimation of tumour proliferation may allow the design of individualised radiotherapy schedules to optimise response. This prospective study correlates the tumour proliferation rate of cervical carcinoma with response to conventional radiotherapy. The potential tumour cell doubling rate (Tpot) was estimated following flash labelling of the tumours in vivo using the DNA precursor, bromodeoxyuridine (BrdUrd); samples were analysed by flow cytometry. Tumour ploidy, DNA index and mitotic count were also assessed as was histological grade and type. Multiple biopsies from each tumour were obtained from 121 women. The median Tpot was 4.0 days, median S-phase duration 12.8 h and median adjusted labelling index 9.8%. Higher BrdUrd labelling was seen in patients who developed pelvic tumour recurrence following radiotherapy. This was the only biological/histological parameter with univariate and multivariate significance in relation to locoregional recurrence (P = 0.006 and P = 0.034 respectively). This study represents the first assessment of Tpot in relation to long-term response of cervical tumours treated by radiotherapy treatment. The association of high BrdUrd labelling and poor pelvic disease-free survival indicates the need for further research into the potential of radiotherapy schedule alteration to reflect tumour proliferation. The predictive value may be enhanced by combination with other biological parameters.

Assessing vulvar lesions. Laser-Doppler flowmetry as a possible technique

Over the last decade, laser-Doppler flowmetry has been used to measure perfusion in the skin. To date it has not been used on the lower genital tract, and we describe preliminary results of measurements taken on the vulva. We include results from a control population and describe two cases with premalignant or malignant changes in the vulva.

HSV-2 increases the mitochondrial aspartate amino transaminase characteristic of tumor cells

A set of polypeptides has previously been described as being immunoprecipitated from tumor cell lysates by the sera of tumor-bearing animals (TBS) or by antisera raised to herpes simplex virus type 2 (HSV-2)-infected cells. These polypeptides were not immunoprecipitated from control cells. The principal polypeptides detected of MW 200, 90 (U90 and L90), 40, and 32 kDa were increased by HSV-2 infection. This communication describes the purification of the 40-kDa protein and its identification by amino acid sequence analysis as being homologous to the mature form of mitochondrial aspartate amino transaminase (mAAT). Two different forms of mAAT were purified and sequenced. One form, of low abundance, was immunoprecipitated by TBS and corresponded to the 40-kDa protein immunoprecipitated from tumor, but not control, cell lysates. Western blotting of the 40-kDa protein immunoprecipitated by TBS showed that it was a form of mAAT found only in tumor cells. The other abundant form reacted in Western blots with antibody to mAAT and was clearly the constitutive enzyme, present in all cells. In general, mAAT was increased up to fourfold after infection with HSV-2, HSV-2 infection also increased mAAT enzyme activity. Northern blotting and quantitative PCR showed that mAAT was induced by HSV-2 at the level of transcription. The specific form of mAAT immunoprecipitated from tumor, but not control, cell lysates could have a role in tumorigenesis, could be a putative tumor cell marker, or could be a target for antitumor drugs. HSV-2 probably induces enzymes of glutamine metabolism because HSV-2 requires glutamine for growth, thus revealing potential new antiviral targets.

Measurement of cell kinetics in cervical tumours using bromodeoxyuridine

The pre-treatment cell kinetics of 120 cervical tumours were assessed following the in vivo labelling with the thymidine analogue Bromodeoxyuridine (BrdUrd). In 89% both static and temporal kinetic parameters could be measured. Through the analysis of multiple biopsies from each tumour marked intra tumour heterogeneity was demonstrated. The median values for the most highly labelled sample analysed for each tumour were; S-phase duration (Ts) 12.1 h, BrdUrd labelling index (CLI) 9.5% and potential tumour doubling time 4.4 days. There was a significant elevation in CLI, but no difference in Ts, between tumour and non-neoplastic cervical tissue. There was a significant elevation in CLI, advanced stage and large size tumours. Although a significant elevation in CLI was found in aneuploid tumours this is likely to represent the systemic bias of the calculation methods, with no difference being seen between aneuploid and diploid tumours when BrdUrd labelling was measured with-out reference to the nuclei DNA content. The majority of these patients were treated with radiotherapy and cell kinetic data will be correlated with treatment response when adequate follow up has been achieved.

Case report: pelvic pain syndrome--successful treatment of a case by ovarian vein embolization

Pelvic pain syndrome, without an apparent organic cause, is a common gynaecological complaint. Investigations, including laparoscopy are frequently negative but ovarian venography has demonstrated that pelvic varices are a consistent finding in these patients. The aetiology of pelvic varices has been the subject of debate, but it has recently been suggested that the primary problem is venous reflux in dilated, incompetent ovarian veins. Surgical ligation of the ovarian veins has been used effectively in small series of patients with this condition. We report a patient with the clinical and radiological features of this syndrome in which treatment by bilateral ovarian venous embolization produced prolonged symptomatic relief.