Trend of decreasing length of cervical cone excision during the last 20 years

OBJECTIVE

The aim of the present investigation was to evaluate the cervical conizations performed in the last 20 years in a single institution, with a particular interest in analyzing the trend of the length of cone excisions.

PATIENTS AND METHODS

A retrospective cohort study of women who underwent a CO2-laser cervical conization between January 1996 and December 2015. Cytological abnormalities on referral pap smear, colposcopic findings and pertinent clinical and socio-demographic characteristics of each woman were collected. In particular, the length of cone specimen was evaluated, taking into account all the factors potentially influencing the length of excision.

RESULTS

A total of 1270 women who underwent cervical conization from January 1996 to December 2015 were included in the analysis. A mean cone length of 15.1 ± 5.7 mm was reported, and we observed a significant decrease in the length of cone excisions over the whole study period. Age (rpartial = 0.1543, p < 0.0001), see & treat procedure (rpartial = -0.1945, p < 0.0001) and grade II colposcopic findings (rpartial = 0.1540, p < 0.0001) were significantly associated with the length of cone excision on multivariate analysis.

CONCLUSIONS

In the last 20 years, a significant decrease in the length of cone excision was observed. In our opinion, this can be due to the acquired awareness by the gynecologists of the potential disadvantages of wide cone excision in term of adverse obstetric outcomes in future pregnancies.

Colposcopic patterns of vaginal intraepithelial neoplasia: a focus on low-grade lesions

OBJECTIVE

The aim of this study was to evaluate the colposcopic patterns observed in women with a histopathological diagnosis of vaginal intraepithelial neoplasia, with a particular interest in analyzing the colposcopic characteristics of low-grade squamous intraepithelial lesions (LSIL).

PATIENTS AND METHODS

Medical charts and colposcopy records of women diagnosed with vaginal intraepithelial neoplasia from January 1995 to December 2015, were analyzed in a multicenter retrospective case series. The abnormal colposcopic patterns observed in women with vaginal LSIL and vaginal high-grade SIL (HSIL) were compared. The vascular patterns and micropapillary pattern were considered separately.

RESULTS

Regardless the histopathological grading, in women with vaginal SIL, the grade I abnormal colposcopic findings were more frequent than grade II abnormalities. However, a grade I colposcopy was more commonly observed in women with a biopsy diagnosis of LSIL rather than HSIL (p<0.0001). Similarly, the micropapillary pattern was more frequently observed in women with LSIL (p=0.004), while vascular patterns were observed more frequently in women diagnosed with vaginal HSIL (p<0.0001). In women with grade I colposcopy, the menopausal status and a previous hysterectomy appeared to be associated with the diagnosis of vaginal HSIL.

CONCLUSIONS

Grade I abnormal colposcopic findings were more commonly observed in women with vaginal LSIL, as well as the micropapillary pattern. On the other hand, grade II abnormal colposcopy and the presence of vascular patterns were more frequently observed in women with vaginal HSIL.

High-grade vaginal intraepithelial neoplasia and risk of progression to vaginal cancer: a multicentre study of the Italian Society of Colposcopy and Cervico-Vaginal Pathology (SICPCV)

OBJECTIVE

The aim of this study was to analyse the women with high grade vaginal intraepithelial neoplasia (HG-VaIN), in order to identify a subset of women at higher risk of progression to invasive vaginal cancer.

MATERIALS AND METHODS

The medical records of all the women diagnosed with HG-VaIN, and subsequently treated, from January 1995 to December 2013 were analyzed in a multicentre retrospective case series. The rate of progression to invasive vaginal cancer and the potential risk factors were evaluated.

RESULTS

205 women with biopsy diagnosis of HG-VaIN were considered, with a mean follow up of 57 months (range 4-254 months). 12 cases of progression to vaginal squamocellular cancer were observed (5.8%), with a mean time interval from treatment to progression of 54.6 months (range 4-146 months). The rate of progression was significantly higher in women diagnosed with VaIN3 compared with VaIN2 (15.4% vs. 1.4%, p < 0.0001). Women with HG-VaIN and with previous hysterectomy showed a significantly higher rate of progression to invasive vaginal cancer compared to non-hysterectomised women (16.7% vs. 1.4%, p < 0.0001). A higher risk of progression for women with VaIN3 and for women with previous hysterectomy for cervical HPV-related disease was confirmed by multivariable logistic regression analysis.

CONCLUSIONS

A higher rate of progression to vaginal cancer was reported in women diagnosed with VaIN3 on biopsy and in women with previous hysterectomy for HPV-related cervical disease. These patients should be considered at higher risk, thus a long lasting and accurate follow up is recommended.

Adjuvant topical treatment with imiquimod 5% after excisional surgery for VIN 2/3

OBJECTIVE

Vulvar intraepithelial neoplasia (VIN) is a premalignant lesion of the vulva. The incidence of VIN is increasing. The surgery is currently the gold standard therapy for VIN, but Imiquimod could be a completion to surgery. The aim of this study is to compare the overall complete response, the recurrence rate and the risk factors for recurrence among two groups of patients: women with high grade VIN underwent surgery and patients treated with surgery plus Imiquimod.

PATIENTS AND METHODS

80 patients with histologically diagnosed VIN 2/3 were enrolled in this prospective study. Our patients were divided into two groups: 40 women underwent surgery (A) and 40 patients were treated with surgery plus Imiquimod (B). All women had a 5-year follow-up. Recurrence rate and complete response were evaluated. The following patients' characteristics were analyzed: smoke, multifocal disease, multicentric disease, degree of the lesion.

RESULTS

In the group A recurrence rate was 44.8%, in the group B it was 48.4%. In both groups the presence of multifocal lesions (p = 0.02) and VIN 3 (p = 0.006) before treatment was associated with a higher risk of recurrence.

CONCLUSIONS

This study found that surgery remains the principal approach for VIN with regard to relapse and complete response since the treatment with Imiquimod associated with surgery didn't show a lower recurrence rate. Although the surgical treatments remain the best therapeutic option for VIN with regard to recurrence and overall complete response, the combined therapy seems to be an interesting modality, but further studies are needed.

Imiquimod 5% cream versus cold knife excision for treatment of VIN 2/3: a five-year follow-up

BACKGROUND

Vulvar intraepithelial neoplasia (VIN) is a premalingnant condition. For long time, surgery was considered the first-line therapy in the treatment of high grade VIN. Imiquimod was recently introduced as an alternative to surgery.

AIM

To compare the overall complete response, the recurrence rate and the risk factors for relapse among patients with VIN 2/3 treated with Imiquimod or surgical excision.

PATIENTS AND METHODS

Eighty women who had histological diagnosis of VIN 2 and VIN 3 were enrolled in this prospective study. Patients immunocompromised, with recurrent VIN, with well differentiated type VIN or VIN 1 and women treated more than once were excluded from the study. Patients were divided into two groups: group A was treated with Imiquimod, group B underwent surgical excision. Patients' characteristics analyzed were: age, smoking, degree of the primary lesion, state of margins, multifocal disease. We have evaluated the recurrence rate, the relapse rate, and the overall complete response, considering as recurrence the onset of a lesion after an initial complete response to Imiquimod and/or after the surgical treatment and as relapse all patients who had a recurrence plus those with medical treatment failure.

RESULTS

Multifocal lesions (p = 0.03) and VIN 3 (p = 0.002) were associated with a higher risk of relapse. The recurrence rate was higher in the group B (p = 0.009), but the relapse rate was higher in the group A (p = 0.04). The overall complete response was better in the group B (p = 0.04).

CONCLUSIONS

Although the advent of new medical options can decrease the morbidity associated with invasive surgical procedures, surgical treatments remain the best treatment modality for VIN with regard to relapse and overall complete response.

Teenagers' knowledge about HPV infection and HPV vaccination in the first year of the public vaccination programme

The aim of this study was to assess teens' knowledge of HPV infection and vaccination one year after the initiation of the public vaccination programme and information campaign on the disease and the opportunity of vaccination. Between 15 May and 15 June 2009, a survey was carried out on 1,105 teenagers attending high schools in a town in the northeast of Italy by means of an anonymous and unannounced questionnaire covering the knowledge of HPV infection, transmission, prevention, vaccination and post-vaccination behaviours. Only 75% of teens knew what HPV infection is (92% of girls vs 51% of boys, p < 0.001); only 70% knew that it is a sexually-transmitted infection. Only 69.3% associated condoms with HPV disease prevention (72.6% girls vs 61.5% boys, p = 0.002). About 18.8% of girls and 33.2% of boys believe that HPV can lead to AIDS (p < 0.001). Among teens aware of HPV vaccination, 7.6% of girls and 21.8% of boys believe that it can prevent AIDS (p < 0.001). Only 75.5% of girls and 51.1% of boys (p < 0.001) believe that condom use remains useful for HPV prevention after vaccination. The need for regular pap smears after vaccination is reported by 93.3% of girls. Teens' knowledge about HPV infection and vaccination remains insufficient, despite a broad information campaign. Erroneous information may increase risky sexual behaviours. Without complete information about HPV infection and vaccination and information about other sexually-transmitted diseases, the latter might become difficult to control among teenagers, while some misunderstandings about the usefulness of secondary prevention might linger.

[Knowledge of HPV-related genital lesions and of anti-HPV vaccination in a sample of women of north-eastern Italy]

AIM

Knowledge of human papilloma virus (HPV) infection and related genital lesions and vaccine is related to the success of the vaccination program. Authors have assessed knowledge, attitudes and beliefs on HPV and vaccination in a sample of women, in order to optimize any educational interventions.

METHODS

This study enrolled 212 consecutive women with no history of HPV-related genital lesions by means of an anonymous questionnaire. The questionnaire included 21 questions (19 with a multiple choice and 2 with open answers) to check awareness of HPV infection and related lesions, HPV transmission, vaccine and vaccination program expectations, sexual/precautionary behaviours after vaccination and the need felt for more information.

RESULTS

Forty-two percent of women in the study population know about HPV-related genital lesions, and 43% are aware of the right way of transmission; 75% have learned about the vaccine. In this last group 28% know that the vaccine efficiency is mainly limited to the HPV types included in the vaccine, 19.8% know that one of the vaccines can also prevent genital condylomata and 88% have heard about this vaccination program.

CONCLUSIONS

There is still a lack of information or access to information about HPV and more needs to be done to raise awareness of HPV vaccination. A percentage of 74.4 of women wish to receive more information and thinks that schools and family planning clinics should play a central role in teenagers' health education. There is a need to further train healthcare workers involved in the vaccination program in order to optimize their counselling to teenagers and parents.

Performance of cytology and colposcopy in diagnosis of cervical intraepithelial neoplasia (CIN) in HIV-positive and HIV-negative women

As part of an extensive multi-institutional DIANAIDS-HIV-HPV-SIL project run in Italy (co-ordinated by ISS), the present study compares the performance (sensitivity, specificity, agreement) of routine cervical smear cytology with that of colposcopy in the detection of histologically-confirmed CIN lesions in 37 HIV-positive and 21 HIV-negative women, belonging to the DIANAIDS cohort of 459 women. All women were subjected to a cervical smear, colposcopy and biopsy, making possible the pairwise comparison of these techniques. In the whole series of HIV-positive and HIV-negative women, cytology had a sensitivity of 86.9% and specificity of 83.3%, the sensitivity of grade 2 abnormality on colposcopy against histology being 82.6% and specificity, 33.3%. No statistically significant difference was observed in the performance of Pap smears between the HIV-positive and HIV-negative women. The sensitivity of cytology was 89.7% vs 82.4% and the specificity, 75% vs 100%. For colposcopy, the sensitivity was 79.3% vs 88.2% and the specificity, 75% vs 50%. These data suggest that cervical Pap smear cytology is a highly sensitive and specific diagnostic tool in the clinical monitoring of lower genital tract pathology in HIV-positive women. Colposcopy, on the other hand, proved to be a somewhat less accurate diagnostic tool in these women.

[Laser surgery in the conservative management of vaginal intraepithelial neoplasms]

BACKGROUND AND AIMS

The increase finding of vaginal intraepithelial neoplasia (VaIN) in young women has led to the need to develop personalized conservative treatment. The authors studied the use of CO2 laser in the treatment of VaIN, evaluating the efficacy, repeatability, complications and the conservation of sexual function.

METHODS

A total of 37 consecutive patients with histologically demonstrated VaIN (10 VaIN 1, 14 VaIN 2 and 13 VaIN 3): mean age 45.3 years, 37.8% aged < 35 years, 20/37 in childbearing age; VaIN was isolated in two patients, synchronous in 22 and in 13 cases it was metachronous with other intraepithelial or invasive genital neoplasia. 30/37 patients were treated with laser surgery as outpatients for a total of 41 operations (37 vaporisations and four excisions) using colposcopic guided CO2 laser with a constant emission power of 35 watts or 30 watts in the pulsed mode, under local anaesthesia, following the application of 5% acetic acid.

RESULTS

Twenty-one (87.5%) of the 24 patients evaluated at 12 months were negative after one (16 patients) or more treatments (from 2 to 5 in 5 patients). Following the second recidivation, one elderly patient preferred traditional demolitive surgery; 2 patients are still awaiting further laser surgery. Five patients with multifocal lesions associated topical treatment with 5-fluorouracil. None of the sexually active patients complained of dyspareunias after treatment.

CONCLUSIONS

Given the lack of other equally effective treatment and with the aim of preserving genital integrity, the authors regard laser surgery as the elective treatment for VaIN 2 and 3.

[Percutaneous endoscopic gastrostomy (PEG) in upper gastrointestinal tract occlusion in gynecologic oncology]

BACKGROUND AND AIMS

Intestinal obstruction is a frequent cause of death in patients suffering from gynecological cancer, who have undergone multiple treatment in the form of surgery and/or chemotherapy and/or radiotherapy. The usual form of rescue treatment consists in the use of a nasogastric tube to administer support and analgesic treatment. Surgical gastrostomy is not a viable proposition in these extremely weak patients with large masses compressing and displacing the stomach. Percutaneous endoscopic gastrostomy (PEG), a technique first introduced for nutritional purposes, can be beneficially used to achieve decompression in these patients.

METHODS

PEG was performed in a total of 67 patients who had already undergone multiple treatment for abdominal-pelvic neoplasia with upper gastrointestinal obstruction, who could no longer be operated and who had a life expectancy of less than sixty days. In three cases positioning was not possible owing to the lack of transillumination of the gastric and abdominal wall. 54/64 patients had previously undergone at least two operations.

RESULTS

Esophagogastric lesions were found in 29% of patients, some of which were attributed to the nasogastric tube. Symptomatic wellbeing was obtained in 76.5% a few days after PEG. PEG remained in situ from 4 to 472 days. Slight peristomal infection was observed in 9% of cases. In seven cases it was necessary to add octreotide owing to the reappearance of symptoms.

CONCLUSIONS

PEG is relatively easy to use and allows obstructive symptoms to be resolved in the majority of patients. Special medical skills are not required and the patient may be easily managed at home together with support therapy and pain management. Once PEG has been performed, it is possible to take fluids and semi-liquid foods, offering the patient a chance to taste flavours which have often been forgotten. PEG enables neoadjuvant chemotherapy to be performed in patients with previously untreated intestinal obstruction.

Maximal cytoreductive surgery as a reasonable therapeutic alternative for recurrent endometrial carcinoma

OBJECTIVE

The objective was to determine if maximal cytoreductive surgery could carry any benefit in pelvic and abdominal recurrent endometrial carcinoma.

METHODS

Twenty women at their first large pelvic or abdominal recurrence from endometrial carcinoma were treated with maximal cytoreductive surgery. Women were classified as R1 (residual tumor) or R0 (no residual tumor) by tumor left at the end of surgery. Adjuvant postoperative therapy was undertaken upon clinical judgement. Progression-free, overall, and cancer-related survivals were analyzed with the product-limit method and compared with the log-rank test. The Cox regression model was used to study the variables involved in progression-free and overall survival.

RESULTS

Complete macroscopic resection of tumor was feasible in 13 women (65%). R0 group women had a significant both progression-free (median reached at 9.1 months) and overall survival (median reached at 11.8 months) compared to R1 group women. There were 2 (10%) perioperative deaths. Eight women died of cancer, 5 in the R1 group and 3 in the R0 group. There were four intercurrent deaths in women still free from the disease. Local control of neoplasia was achieved in 84.6% of R0 women and their survival was affected mostly by distant recurrences or intercurrent deaths. Residual tumor at the end of surgery was the only significant variable to affect both progression-free and overall survival.

CONCLUSION

Intensive surgery is a valid treatment option in women with large pelvic or abdominal recurrence from endometrial carcinoma. Tumor can be completely resected and local control of the disease can be achieved in most of the patients, although survival could be affected by distant recurrence and intercurrent deaths.

Intra-epithelial and invasive cervical neoplasia during HIV infection

Patients affected by human immunodeficiency virus (HIV) infection present an elevated risk of developing cancer. In the last 10 years, the relationship between human papilloma virus (HPV) infection and female cervical intra-epithelial neoplasia (CIN) has been established. Several studies have described an increased prevalence of both cervical HPV infection and CIN among HIV-positive women compared to HIV-negative ones. A high recurrence rate of CIN after standard treatment has been noted in HIV-infected women and the severity of these lesions seems to be inversely correlated to immune function. Taking into account these data, the Centers for Disease Control (CDC) since 1993 have included invasive cervical carcinoma among the AIDS-defining conditions. Once cervical cancer develops in HIV-positive women, the disease may be aggressive and less responsive to treatment. A primary means by which HIV infection may influence the pathogenesis of HPV-associated cervical pathology is by molecular interaction between HIV and HPV genes. Although these have not been well defined, an upregulation of HPV E6 and E7 genes expression by HIV proteins (such as tat) has been postulated by some authors. Cervical cytology appears to be adequate as a screening tool for the cervical intra-epithelial neoplasia in HIV-positive women, but the high recurrence rate and multifocality of this disease reinforces the need for careful evaluation and follow-up of the entire anogenital tract in these women. Probably in the next few years, cervical tumours will represent one of the most frequent complications of HIV infection, a part of progression through AIDS. This points to a need for greater interdisciplinary co-operation for a best disease definition and for the development of effective prevention measures.

Squamous intraepithelial cervical lesions in human immunodeficiency virus-seropositive women

OBJECTIVE

To evaluate the relationship between human immunodeficiency virus (HIV) infection, CD4 serum level, cervical squamous intraepithelial lesions (SILs) and risk factors for human papillomavirus (HPV)-related dysplasia in HIV-positive women.

STUDY DESIGN

All 51 eligible patients who were seen at the Colposcopic Outpatient Service, Aviano Cancer Center, Aviano, Italy, from July 1, 1993, to June 30, 1994, were studied for risk factors for HPV and HIV infection and had cervical cytologic smears, colposcopy with cervical biopsy and a serum CD4 count.

RESULTS

Thirty of 51 patients (59%) had cytohistologically confirmed SIL. The prevalence of SIL was higher in HIV Centers for Disease Control stage IV disease than stages II and III (22/29 vs. 8/22 P < .05). There was no significant difference in the CD4 count between women with or without SIL (321 +/- 310 vs. 401 +/- 295/mm3 [mean +/- SD]). No relationship was found between CD4 count and severity of SIL (low grade SIL, 210 +/- 203/mm3; high grade SIL, 580 +/- 357/mm3).

CONCLUSION

In our series there was no relationship between CD4 count and cervical SIL, suggesting that the expression of HPV-related dysplasia is a complex process in which risk factors for genital SIL play an important role, while the role of HIV must be defined again.

Diagnostic and biological determinants in undifferentiated and poorly differentiated ovarian carcinomas

Six ovarian undifferentiated carcinomas (UCs) and 19 poorly differentiated serous (14 cases) and endometrioid (5 cases) carcinomas with areas of solid diffuse carcinomas have been considered for the study. Pathological findings were analyzed in conjunction with molecular analysis concerning the structure and expression of nm23-H1 gene. Differences in the frequency of loss of heterozigosity (LOH) of this gene have been observed between the two groups, UCs displaying lower percentage of LOH (1/5) as compared to poorly differentiated tumors (17/17). The remaining 3 cases (1 UC and 2 poorly differentiated carcinomas) were homozygotes, i.e., noninformative. UCs might occur as a consequence of cellular dedifferentiation, being at the end of the differentiation spectrum of epithelial ovarian tumors. Nevertheless, this study suggests that, in a fraction of cases, UCs could represent a distinct entity not involved in the malignant progression, associated with peculiar DNA anomalies, one possibly being that of the nm23-H1 deletion. In other words, a noticeable subset of UCs, not harboring nm23-H1 alterations, may be histologically uncommitted "ab initio". Moreover, nm23-H1 LOHs could be considered early events in the ovarian carcinogenesis, because similar molecular patterns were found both in primary and metastatic sites of the same tumor.

Suppressive role of the metastasis-related nm23-H1 gene in human ovarian carcinomas: association of high messenger RNA expression with lack of lymph node metastasis

The nm23-H1 gene has been proposed as a metastasis suppressor gene. It is located on the long arm of chromosome 17, which is frequently deleted in ovarian cancer, and shows altered expression and structure in some advanced neoplasms. To evaluate the role of nm23-H1 in ovarian carcinogenesis, we have analyzed this gene in 66 primary human ovarian carcinomas at both the DNA and RNA levels. Despite the high frequency (76%) of nm23-H1 loss of heterozygosity (LOH), the complete absence of gene mutations in the coding portions of the retained allele clearly indicated that, in ovarian carcinomas, this gene does not function in the same way as do classic oncosuppressor genes. The relationship of clinicopathological parameters with nm23-H1 gene deletions and expression levels was also investigated. LOHs were more common in the serous and endometrioid histotypes (85 and 93%, respectively), and the highest LOH frequency was detected in poorly differentiated tumors (89%). A significant relationship between nm23-H1 mRNA expression and lymph node metastasis was observed in high-grade tumors, which are intrinsically more invasive than are low-grade tumors. In particular, among the poorly differentiated tumors showing areas of undifferentiated solid carcinoma (classified as G3/G4), lymph node-negative tumors displayed expression levels that were significantly higher than those of lymph node-positive tumors (P < 0.001). In conclusion, our data suggest that the nm23-H1 gene product may exert an inhibitory effect on the lymphatic dissemination of human ovarian tumors. However, several other factors, biological or time and patient dependent, influence the complex metastatic progression of ovarian tumors and may cooperate with nm23-H1 in the promotion or inhibition of this process.

Squamous cell carcinoma in ovarian endometriosis. A case report

A primitive squamous cell carcinoma of the ovary arose in ovarian endometriosis. The patient underwent a radical hysterectomy and radiotherapy. The other few similar reported cases had a poor prognosis. In our case the patient died 11 months after surgery.

[Laser conization guided by endocervical staining with methylene blue]

The authors report their experience of the use of a vital stain--methylene blue--as a surgical guide in laser cervical conization for CIN2-CIN3/CIS. During the period 1 October 1991-31 December 1992 a total of 40 laser cervical conizations were performed under local anesthesia using a CO2 laser connected to a microhandpiece and colposcope in patients with exo-endocervical lesions which were histologically positive for CIN2-CIN3/CIS. In 33/40 patients an aqueous solution of 1% methylene blue was introduced preoperatively in the endocervix using a cotton-wool bud with consequent impregnation of the pseudoglandular crypts: laser biopsy was performed along the guidelines of the stain itself. This enabled the direction of resection to be varied: in 3 patients due to an anomalous and eccentric direction of cervical canal; in 10 patients to remove glandular structures surrounding or underneath lesions; in 8 patients following pseudoglandular section to carry out deep vaporization (3 patients) or correct cutting edges (5 patients). The apex and edges of the cone were always intact. Fourteen patients completed a 12-month follow-up and a further 6 were followed up for 9 months; only 1/14 patients (with AIDS) showed recidivation after 1 year. In the authors' experience the use of a vital stain as a guide during laser cervical cone biopsy is an easily used method which ensures the greatest possible respect for healthy cervical structures, also in order to preserve fertility in young patients.

[Second surgery in the management of ovarian cancer]

The aim of this study was to evaluate the value of second surgery in the combined and multidisciplinary treatment of mullerian ovarian cancer. A retrospective study was carried out in 86 consecutive patients with advances stages of mullerian ovarian cancer (stage 3-4) referred to the Division of Gynecological Surgical Oncology of the Oncological Reference Centre at Aviano for continuation of treatment following initial surgery and chemotherapy performed in various peripheral institutions. Second surgery only revealed 11.6% of complete endocelomatic pathological responses (10 patients) to earlier treatments; among the 76 patients with persistent disease it was possible to achieve optimal redebulking in 50 (65.8%) (31 R0 and 19 R1 after second surgery), whereas it was not possible to perform adequate second surgery in 26 (34.2%). The impact of second surgery on the probability of survival (mean survival rate) was highly significant in the 50 patients in whom it was possible to perform adequate second surgery compared to the non-operated group (14.34 months versus 6.10, chi square = 12.671, p = 0.0004). The authors underline both the prognostic value of lymph node status with increased mortality among patients with positive retro-peritoneal lymph nodes (LN+), and the value of retroperitoneal re-evaluation in predicting endo-peritoneal recidivation in patients with free abdomen who subsequently relapsed.

Chromosomal localisation of two putative 11p oncosuppressor genes involved in human ovarian tumours

In this study, 44 primary or metastatic human ovarian tumours were tested for allelic deletions on the short arm of chromosome 11. Analysis of 12 polymorphic loci by Southern blotting evidenced loss of heterozygosity (LOH) in at least one locus in 41% of cases. Moreover, two hot spots of deletions were tentatively mapped on 11p13 and 11p15.5. Our results demonstrated that LOH at 11p is a common event in ovarian carcinomas and were indicative of the possible existence in 11p of two oncosuppressor genes involved in ovarian carcinogenesis. The similarity observed with 11p allelic losses in Wilms tumours, clustered in 11p13 and 11p15.5 too, suggests that deletion and possibly inactivation of the same growth regulatory genes (WT genes) could also contribute to development of the malignant phenotype in ovarian carcinomas. Finally, a statistically significant association (P = 0.005) between 11p deletions and hepatic involvement was suggested by the analysis of distribution of 11p LOH relative to different clinical and pathological parameters of the tumour patients.

[Local anesthesia in cervix biopsy]

The Authors evaluated the perception of pain in a group of 35 patients undergoing cervical biopsy and the efficacy of using 40 mg of lydocaine (xylocaina spray) in 24 patients compared to a control group. Pain perception was evaluated using Scott-Huskissons's visual analogous scale. It was observed that this diagnostic method was painful and that premedication using topical anesthesia was an efficacious method of significantly reducing painful symptoms.

[True knots in the umbilical cord: clinical implications]

A study was performed to study the behavior of various parameters of fetoplacental functions and fetal and neonatal well-being in 51 cases with the presence of true knots in the umbilical cord at birth. No statistically significant difference was observed when these cases were compared to a control group without this pathology. The Authors underline the need for precise statistical evaluations in order to reassess the clinical significance of such umbilical alterations.

[Reliability of cytodiagnosis from washings and free fluid in the staging and follow-up of ovarian tumors]

181 diagnostic correlations between endocelomatic free-fluid or washing cytology and histological findings during staging or follow-up of patients suffering from ovarian cancer have been assessed. On the basis of the evaluation of the sensitivity and specificity of endocelomatic cytology, its importance in diagnostic protocols for evaluating the presence or persistence of disease is reiterated.

[Bilateral hydrothorax with hydromediastinum after cannulation of the left internal jugular vein]

A rare case of combined bilateral hydrothorax and hydromediastinum was encountered during Total Parenteral Nutrition (TPN) via incannulation of the left internal jugular vein in a patient with advanced cancer of the portio. The possible anatomical and technical causes of this very serious complication were investigated in order to assess the importance of specific manual technique and to supply appropriate instrumental back-up that could prevent the recurrence of this sometimes fatal complication of TPN.

Intermittent pelvic arterial infusion with peptichemio, doxorubicin, and cisplatin for locally advanced and recurrent carcinoma of the uterine cervix

The preliminary results of intraarterial chemotherapy with peptichemio, doxorubicin, and cisplatin as part of a multimodality treatment in locally advanced and recurrent cervical carcinomas are reported. Treatment consisted of a bilateral sequential infusion of peptichemio 20 mg, doxorubicin 10 mg and cisplatin 20 mg in a 6-hour period via an external infusion pump. After a rest period of 4 days, treatment restarted until maximum response or toxicity. Twenty-five patients, 12 with primary advanced (four Stage IIb, eight Stage III) and 13 with recurrent tumors were treated. All previously untreated patients obtained objective response. In particular, two patients with Stage IIb and III disease, respectively, achieved a complete response. Nine of 13 patients with recurrent disease (69%) were responsive, too, and therefore an overall objective response rate of 84% was achieved. Responses were noted after a median of five cycles of chemotherapy, whereas hematologic toxicity observed in all but one patient, was encountered after a median of four cycles. Toxicity of grade 1 and 2 was noted in 19 patients (76%), whereas of grade 3 and 4 in only 5 (20%). One treatment-related death, due to sepsis during myelosuppression, was reported. Catheter-related toxicity was noted in four patients causing femoral thrombosis in two. In one case a bypass operation was required. After intraarterial chemotherapy, all 21 responsive patients were eligible for radical surgery and 18 (86%) underwent both surgery and postoperative radiation therapy. Surgery was excluded in three patients. In these three cases radiation therapy alone was employed. In this series, the schedule of intraarterial chemotherapy employed was very effective. Patient accrual is ongoing in order to confirm the response rate so far obtained and to evaluate, with a longer follow-up, the impact of this multidisciplinary approach on local control and survival.

[Antineoplastic agents and pregnancy]

The current impossibility of establishing a definite causal relationship between the administration of antineoplastic drugs before and/or during pregnancy and possible modifications of the gestational attitude in the treated women is discussed after a review of the Literature. The data till now reported are often deficient as far as concerns the evaluation of either the fetal, perinatal and post-natal parameters and the past and current reproductive performance of the patients on study. The need for strict methodology in the study and report of feto-maternal parameters to provide a comprehensive answer to the questions raised by the use of antineoplastic drugs before and/or during pregnancy is discussed in detail.