Exome sequencing in every pregnancy? Results of trio exome sequencing in structurally normal fetuses

OBJECTIVE

This study aimed to assess the detection rate of clinically significant results of prenatal exome sequencing (pES) in low-risk pregnancies and apparently normal fetuses in non-consanguineous couples.

METHODS

A retrospective analysis of pES conducted at a single center from January 2020 to September 2023 was performed. Genetic counseling was provided, and detailed medical histories were obtained. High-risk pregnancies were excluded due to major ultrasound anomalies, sonographic soft markers, abnormal maternal biochemical screening, or family history suggestive of monogenic diseases as well as cases with pathogenic and likely pathogenic (P/LP) chromosomal microarray results. Exome analysis focused on ∼2100 genes associated with Mendelian genetic disorders. Variant analysis and classification followed the American College of Medical Genetics and Genomics (ACMG) guidelines.

RESULTS

Among 1825 pES conducted, 1020 low-risk cases revealed 28 fetuses (2.7%) with potentially clinically significant variants indicating known monogenic diseases, primarily de novo dominant variants (64%). Among these 28 cases, 9 fetuses (0.9%) had the potential for severe phenotypes, including shortened lifespan and intellectual disability, and another 12 had the potential for milder phenotypes. Seven cases were reported with variants of uncertain significance (VUS) that, according to the ACMG criteria, leaned toward LP, constituting 0.7% of the entire cohort. Termination of pregnancy was elected in 13 out of 1020 cases (1.2%) in the cohort, including 7/9 in the severe phenotypes group, 2/12 in the milder phenotype group, and 4/7 in the VUS group.

CONCLUSION

The 2.7% detection rate highlights the significant contribution of pES in low-risk pregnancies. However, it necessitates rigorous analysis, and comprehensive genetic counseling before and after testing.

Exploring inheritance, and clinical penetrance of distal Xq28 duplication syndrome: insights from 47 new unpublished cases

BACKGROUND

Distal Xq28 duplication, or int22h1/int22h2-mediated Xq28 duplication syndrome, leads to cognitive impairment, neurobehavioral issues, and facial dysmorphisms. Existing literature has limited information on clinical traits and penetrance.

METHODS

We identified cases of distal Xq28 duplication (chrX: 154,126,575-154,709,680, GRCh37/hg19) through a review of clinical records and microarray reports from five centers, encompassing both postnatal and prenatal cases, with no prior family knowledge of the duplication.

RESULTS

Our search found 47 cases across 26 families, with duplications ranging from 208 to 935 Kb. In total, 8 out of 26 index cases featured a 200-300 kb partial duplication, mainly from Armenian/Caucasian Jewish backgrounds. Most prenatal cases showed no major fetal ultrasound malformations. Of cases with known inheritance mode (15 out of 26), maternal inheritance was more common (80%). The study identified seven male carriers of the duplication from six unrelated families, indicating partial penetrance in males.

CONCLUSION

Our study provides key insights into distal Xq28 duplication. Most prenatal tests showed no major fetal ultrasound issues. Maternal inheritance was common, with unaffected mothers. In the postnatal group, a balanced gender distribution was observed. Among male family members, two fathers had ADHD, one was healthy, and one brother had mild symptoms, indicating partial penetrance in males.

P1791Conduction abnormalities following aortic valve intervention in patients with transthyretin cardiac amyloidosis

Introduction

Aortic Stenosis (AS) is the most common valvular heart disease in the Western world. Transcatheter aortic valve implantation (TAVI) is an alternative to surgical valve replacement in medium and high-risk patients. One of the most common complications after TAVI is conduction system disturbances including bundle branch block, complete heart block and need for permanent pacemaker implantation. Transthyretin cardiac amyloidosis (TTR–CA) is an increasingly recognized cause of heart failure that almost exclusively affects older adults. Diagnosis of TTR-CA in patients undergoing valvular intervention is relevant to understand their clinical outcomes and to discuss specific management.

Objectives

Occult amyloid may account for the frequent need for pacemakers among TAVR patients. We aimed to assess the correlation between intervention induced conduction abnormalities and the need for a pacemaker insertion and the presence of TTR-CA.

Methods

The study population included patients who had aortic valve intervention between 2011–2018. The patients underwent Tc99m-PYP scan using SPECT technology which has been shown to be valid for the diagnosis of TTR-CA. We examined the rate of conduction disorders and the need for a permanent pacemaker from patient files at the time of hospitalization and during a 24-month follow-up.

Results

The study population included 86 patients, mean age 78±6 years, 55% women. Twenty-nine (33%) of the participants were diagnosed as positive (VAS 2 and 3) for transthyretin cardiac amyloidosis. There were no differences in baseline characteristics with regard to age, gender, risk factors, hemoglobin and renal function between patients positive and negative for TTR CA. Conduction disorders were seen in 35 (40%) patients. Patients with TTR CA had a statistically higher prevalence of conduction disorders. Forty-two percent of TTR CA positive patients underwent peri-procedural permanent pacemaker implantation compared to 28% peri-procedural pacemaker implantations in the negative group (p=0.043). Development of a new left bundle branch block during the follow-up period was observed in 14.1% of all patients. There was a statistically significant higher rate in the positive group compared to TTR CA negative group (39.1% vs 10.9% p=0.03).

Conclusions

We observed a high prevalence of occult TTR-CA in older adults with aortic stenosis who underwent TAVI. We also found a high prevalence of conduction abnormalities following TAVI in patients with TTR CA. These findings suggest a need for more careful observation for possible conduction abnormalities and requirement for pacemaker insertion in these patients.

Acknowledgement/Funding

None

P911High rate of cardiac amyloidosis in elderly patients with aortic stenosis: clinical presentation before and after aortic valve intervention

Background

Aortic Stenosis (AS) is the most common valvular heart disease in the Western world. Wild-type transthyretin amyloid (wtATTR) affects the heart, causing restrictive cardiomyopathy. Deposits can be found in up to 25% of individuals >85 years of age at autopsy. Recently several reports showed a relatively high prevalence of transthyretin cardiac amyloidosis (TTR-CA) in patients with AS.

Objectives

The aim of this study was to examine the clinical effects of TTR-CA in patients who have undergone aortic valve replacement therapy and evaluate the outcome of the intervention.

Methods

We recruited patients who underwent surgical (AVR) or percutaneous (TAVI) aortic valve intervention between 2011 and 2018. The patients underwent a Tc99m-PYP scan using SPECT technology which has been shown to be valid for the diagnosis of TTR-CA. We reviewed patient files before (time point 1) and after intervention (time point 2) and at 2 years (time point 3) follow up, and collected data on hospitalizations, laboratory, and echocardiography.

Results

The study included 86 patients, mean age 78±6 years, 55% women. Twenty-nine (33%) participants were diagnosed as positive (VAS 2 and 3) for transthyretin cardiac amyloidosis.There were no differences in baseline characteristics between patients with and without TTR-CA in cardiovascular risk factors and co-morbidities, laboratory parameters and nutritional status. There were no differences in baseline echocardiographic parameters including valve gradients and left ventricular hypertrophy. However, the patients with TTR CA had more advanced diastolic dysfunction compared to patients without TTR CA (P=0.03) and higher pulmonary artery pressure (44±14.75mmhg vs 30.5±11.38mmhg, p=0.06). Before the intervention, patients with transthyretin cardiac amyloidosis had 3.26 times more hospitalizations due to heart failure as compared to patients in the negative group (p=0.01).

After the intervention, diastolic function remained more severely affected in the positive group at all follow-up points compared to the negative group (p=0.05). Similar observations were seen in the measurements of pulmonary arterial pressure (p=0.019 at time 2 and p=0.015 at time 3). Consistent with the echocardiographic findings, patients with transthyretin cardiac amyloidosis had 2.84 times more hospitalizations after intervention for heart failure than patients in the negative group (p=0.02).

Conclusions

Co-existence of transthyretin cardiac amyloidosis and aortic stenosis in the older population is associated with a more severe clinical presentation and with more advanced clinical and echocardiographic signs of heart failure. Improvement after valvular intervention might be limited in terms of symptoms and hospitalizations in this subgroup.

Acknowledgement/Funding

None

Virulence ofStreptococcus pneumoniaemay be determined independently of capsular polysaccharide

Mice were inoculated intranasally with Streptococcus pneumoniae isolates of serotype 14 with different genetic backgrounds (14R, 14DW) and a capsular switch of 14R, strain 9VR (serotype 9V). Inoculation of the mice with 14R and 9VR resulted in 60% mortality. All the mice survived 14DW inoculation. No differences in lungs' bacterial loads were found 3 h following inoculation. Bacterial clearance of 5 logs was observed 48 h after inoculation with 14DW versus within 1 log 48 h after inoculation with 14R and 9VR. No significant differences in bacterial size or the capsular amount could be found between 14R and 14DW. We conclude that factor(s) in addition to the capsule, contribute to disease outcome.

Differential activation of the immune system by virulent Streptococcus pneumoniae strains determines recovery or death of the host

Streptococcus pneumoniae infection may result in asymptomatic carriage, mucosal or invasive disease. We hypothesize that self-limiting or fatal disease outcome follows infection with S. pneumoniae differential activation of the host immune response. BALB/c and C57BL/6 mice were inoculated intranasally with S. pneumoniae serotype 3 strain WU2 and serotype 14 strain DW14 and mortality, bacterial load, pathological changes in the lungs and cytokines mRNA levels in the spleen were analysed. No differences between the C57BL/6 and the BALB/c inbred mice were observed except for the severity of their lung pathology and IL-4 expression. Infection of the two mouse strains with S. pneumoniae WU2 resulted in sepsis and death that occurred within 4 days post-inoculation. This death was preceded, in both mouse strains, in an increase over time of the lung bacterial load and bacteraemia. The lung pathology was characterized by diffuse pneumonia with marked congestion of the lungs. Analysis of mRNA expression of cytokines in the spleen revealed no alterations in tumour necrosis factor (TNF)-alpha, transforming growth factor (TGF)-beta, interleukin (IL)-12 and interferon (IFN)-gamma and induction of IL-10 and IL-4. The two strains of mice survived infection with S. pneumoniae DW14. This was accompanied by a reduction over time of lung bacterial load and bacteraemia. The lung pathology was characterized by focal lymphocyte infiltration and preserved architecture of the organ. Analysis of mRNA expression of cytokines in the spleen revealed a significant decrease in the levels of TNF-alpha, TGF-beta, IL-12 and IFN-gamma mRNA expression, which usually precedes cytokine protein expression. Interestingly, a significant increase in the levels of IL-4 mRNA expression was found in BALB/c mice only. This study suggests that differential activation or evasion of cytokine expression by S. pneumoniae virulent strains determines disease outcome regardless of the host's immunogenetic background.

Age-dependent preference in human antibody responses to Streptococcus pneumoniae polypeptide antigens

Vulnerability to Streptococcus pneumoniae is most pronounced in children. The microbial virulence factors and the features of the host immune response contributing to this phenomenon are not completely understood. In the current study, the humoral immune response to separated Strep. pneumoniae surface proteins and the ability to interfere with Strep. pneumoniae adhesion to cultured epithelial cells were analysed in adults and in children. Sera collected from healthy adults recognized Strep. pneumoniae separated lectin and nonlectin surface proteins in Western blot analysis and inhibited on average 80% of Strep. pneumoniae adhesion to epithelial cells in a concentration-dependent manner. However, sera longitudinally collected from healthy children attending day care centres from 18 months of age and over the course of the following 2 years revealed: (a) development of antibodies to previously unrecognized Strep. pneumoniae surface proteins with age; (b) a quantitative increase in antibody responses, measured by densitometry, towards separated Strep. pneumoniae surface proteins with age; and (c) inhibition of Strep. pneumoniae adhesion to epithelial cells, which was 50% on average at 18 months of age, increased significantly to an average level of 80% inhibition at 42 months of age equalling adult sera inhibitory values. The results obtained in the current study, from the longitudinally collected sera from healthy children with documented repeated Strep. pneumoniae colonization, show that repeated exposures are insufficient to elicit an immune response to Strep. pneumoniae proteins at 18 months of age. This inability to recognize Strep. pneumoniae surface proteins may stem from the inefficiency of T-cell-dependent B-cell responses at this age and/or from the low immunogenicity of the proteins.

Apoptosis (programmed cell death) in colonic cells: from normal to transformed stage

We determined apoptosis in whole rat colonic tissue and in isolated colonocytes from the various rat crypt regions in preneoplastic stages up to frank neoplasia following administration of the procarcinogen, dimethylhydrazine (DMH). Apoptotic cells were determined by the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end labeling (TUNEL)-method, by evaluating sections stained with hematoxylin and eosin, and caspase-1 immunostaining. Apoptotic cells in whole colonic tissue from untreated rats were confined to the upper crypt while, in DMH-treated rats apoptotic and caspase-1 positive cells were located in the crypt proliferative regions. Numerous apoptotic and caspase-1-positive cells were found in sections from early tumors while in the delayed tumors, apoptotic-positive cells were absent and number of caspase-1-positive cells was negligible. A marked reduction in the apoptotic index along the crypt was observed in isolated transformed colonic cells, this was not the case for caspase-1-positive cells. We conclude that: (i) in colorectal tumors at progressive stage apoptosis is altered, (ii) the mechanistic alteration in apoptosis may be located between caspase-1-protease activity and the fragmentation process of DNA.

Intraoperative lymphatic mapping in cervix cancer patients undergoing radical hysterectomy: A pilot study

OBJECTIVE

Intraoperative lymphatic mapping and sentinel lymph node identification (SLN) have been increasingly evaluated in the treatment of a variety of solid tumors, particularly breast cancer and melanoma. We sought to evaluate the feasibility of these procedures in patients undergoing radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer.

METHODS

Twenty patients with normal-appearing lymph nodes underwent intracervical injection of isosulfan blue dye (lymphazurin 1%) at the time of planned radical hysterectomy and bilateral pelvic/low paraortic lymphadenectomy (40 nodal basins). Regional lymphatic tissue was inspected for dye uptake into lymphatic channels and lymph nodes. Tumor characteristics, surgical findings, and specific locations of lymphatic dye uptake were recorded and correlated with final pathology results.

RESULTS

Sentinel lymph nodes were identified in 12 of 20 (60%) patients. A total of 23 sentinel nodes were identified in 17 of 40 (43%) nodal basins dissected (range: 0-2 per basin). Successful SLN identification was less likely in patients with tumors >4 cm compared with those with tumors </=4 cm (P = 0.035). Of 4 patients with metastatic nodal disease, 3 had tumor involving a SLN; the fourth had no identifiable SLN (inadequate study). In all, 3 of 8 lymph nodes with confirmed metastatic disease were identified using this technique.

CONCLUSION

SLN identification and intraoperative lymphatic mapping are feasible and safe. Lymphatic dye uptake appears to be less reliable in patients with larger tumors. Although sentinel node pathology was representative of the lymphatic basin sampled in all cases, the rate of SLN identification was low with this technique. Lymphatic mapping procedures should be further investigated in the treatment of early cervix cancer.

Initial steps in Streptococcus pneumoniae interaction with and pathogenicity to the host

Streptococcus pneumoniae (Pnc) is one of the leading pathogens in the world. Attachment to respiratory mucosal and lung surfaces is presumed to be involved in carriage, in disease and in the interaction with macrophages initiating innate immune responses. We hypothesized that bacterial adhesins mediate Pnc adhesion and host cell invasiveness. Initial studies have focused on the purification of cell wall and membrane proteins using fetuin affinity chromatography, SDS PAGE and western blot analysis probed with pooled healthy human sera. Using a Pnc clinical isolate, and a gpt mutant we have detected 10-lectin proteins isolated from the cell wall and adherent to the affinity column and 15 lectins isolated from membrane extracts. The fetuin-captured lectins agglutinated rabbit erythrocytes. 15 proteins in the cell wall and 18 proteins in the membrane that failed to bind to the fetuin column did not agglutinate rabbit erythrocytes. Further purification of the cell wall and membrane fetuin-separated fractions was achieved via anion exchange FPLC, was verified by SDS PAGE. These proteins maintained their agglutinating activity, and were subsequently tested for their ability to interfere with Pnc adhesion and invasion of epithelial cells in culture. Additional biochemical, immunological and molecular techniques are being used in attempt to identify relevant proteins.

Extensive apoptotic death of rat colonic cells deprived of crypt habitat

Apoptosis in cells of different lineages is restrained by survival signals which depend upon cell-to-cell communication. The aim of this study was to determine whether colonic cells deprived of crypt ambient are doomed to die prior to their normal chronological demise. Apoptosis was studied in rat whole colonic tissue, in isolated intact crypts, and in colonic cell populations collected from the crypt axis at different stages of proliferation and differentiation. In a number of experiments, cell harvest was performed in the presence of either a tetrapeptide (YVAD-CMK) inhibitor of interleukin-1beta-converting enzyme (ICE), or tyrphostin A25, a protein tyrosine kinase inhibitor, or sodium-orthovanadate, a phosphatase inhibitor. DNA fragmentation was assessed by electrophoretic and nonisotopic-labeling procedures. The ultrastructure of colonic tissue specimens and isolated cells was examined by transmission electron microscopy. Apoptosis in whole colonic tissue and in isolated crypts was confined predominantly to cells resident in the upper crypt regions. In contrast, extensive apoptotic death was observed in isolated colonic cells, irrespective of their developmental stage and positional hierarchy within the crypt continuum at harvest time. An apoptotic gradient, however, was evident. Exposure to YVAD-CMK resulted in a marked decrease in the number of apoptotic cells. Treatment with tyrphostin A25 caused a sharp rise in the apoptotic index; conversely, vanadate significantly impeded apoptosis. Cumulatively, these results indicate that disordered intercellular communication provokes unscheduled ICE-mediated apoptosis of colonocytes, and that local signals along the crypt continuum control both the reprieve from death and the timely demise of distinct colonic cell populations. Attenuation of tyrosine phosphorylation may be a contributory event in the acquisition of the apoptotic phenotype.

Pathology slide review in gynecologic oncology

OBJECTIVE

To analyze the diagnostic accuracy and alteration in treatment planning from interinstitution (different institution) pathologic consultation.

METHODS

We reviewed pathologic reports from 720 referred patients. The diagnosis rendered from a gynecologic pathologist was compared with the original diagnosis. Discrepancies were coded as none, minor, or major. A discrepancy was major if it led to treatment alteration. A discrepancy was minor if it did not lead to treatment alteration. The judgment to declare a discrepancy was made by a gynecologic pathologist, a gynecologist, and three gynecologic oncologists. The review cost was $150 per case. The Cochran-Mantel-Haenszel test evaluated any systematic pattern in discrepancies.

RESULTS

Seven hundred twenty specimens consisted of 113 vulvar, 170 uterine, 289 cervical, 105 ovarian, and 43 vaginal tissues. Six hundred one (84%) pathologic diagnoses showed no discrepancy. There were 104 (14%) minor and 15 (2%) major discrepancies. After reviewing 15 major discrepancies, six surgeries were canceled, two surgeries were modified, one adjuvant radiation treatment was added, one chemotherapy treatment was modified, and five adjuvant chemotherapy treatments were cancelled. No systematic error was identified with regard to the sources (tissue origin) or methods of obtaining the specimen (P = .675). The cost of reviewing 720 specimens was $108,000. The cost of identifying each major discrepancy was $7200.

CONCLUSION

Reviewing pathology slides before definitive treatment reveals notable discrepancies in diagnoses. The cost of pathology review is globally expensive but has consequential impact on proper treatment planning for the individual patient.

Remission of refractory gestational trophoblastic disease in the brain with ifosfamide, carboplatin, and etoposide (ICE): first report and review of literature

Gestational trophoblastic disease (GTD) metastatic to the brain has a very poor prognosis with a survival rate of less than 25%, especially for patients in whom brain metastases develop while on or after chemotherapy. Cure can be achieved by chemotherapy alone. The regimen of etoposide, methotrexate, actinomycin-D, vincristine, and cyclophosphamide has shown encouraging results and is considered to be standard first-line treatment for high risk patients. For patients in whom this regimen fails, a salvage chemotherapy regimen is used. The combination of ifosfamide, carboplatin, and etoposide (ICE) has synergistic activity in preclinical studies. This regimen has shown activity in metastatic breast cancer and non-small-cell lung cancer as well as platinum-resistant germ-cell tumors and metastatic GTD. This is the first report of a patient with a highly refractory GTD in whom brain metastasis developed while on chemotherapy, and whose brain metastasis went into remission with a low dose ICE regimen. Accordingly, ICE may be considered for patients with chemotherapy refractory GTD metastatic to the brain.

Remission of refractory gestational trophoblastic disease with high-dose paclitaxel

High-risk metastatic gestational trophoblastic disease (GTD) in patients who have failed primary chemotherapy has a very poor prognosis. About 25% of women with high-risk metastatic disease become refractory to EMA-CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide and vincristine) and fall to achieve a complete remission. Currently, there is no standard salvage chemotherapeutic regime for EMA-CO failure. Paclitaxel, a taxane analog extracted from the bark of the western yew (Taxus brevlfolla), has shown antitumor activity in a variety of cancer cell lines. High in vivo efficacy was confirmed in phase II trials, especially for breast and epithelial ovarian cancer patients. Recently, two in vitro studies have shown that paclitaxel is a highly effective antineoplastic agent in choriocarcinoma cell lines. We present the first clinical report of a serologic remission with high-dose paclitaxel (250 mg/m2 i.v. infusion over 24 h every 3 weeks) of a highly refractory GTD in a patient who developed brain metastasis after multiple combined chemotherapeutic regimens. The patient tolerated paclitaxel with granulocyte colony stimulating factor support very well. The remission with paclitaxel in this patient confirms its preclinical activity in high-risk, refractory GTD.

Therapy of stage III (optimal) epithelial carcinoma of the ovary with melphalan or melphalan plus Corynebacterium parvum (a Gynecologic Oncology Group Study)

A randomized prospective therapy trial in patients with stage III optimal epithelial carcinoma of the ovary was accomplished by the Gynecologic Oncology Group. Therapy with melphalan or melphalan plus immuno-adjuvant, Corynebacterium parvum (C. parvum), was utilized as adjuvant treatment following surgical therapy. One hundred eight-five patients were eligible for evaluation with 87 patients in the melphalan group and 98 patients in the melphalan plus C. parvum group. The comparison of the treatment regimens showed no differences with respect to either progression-free interval or survival. However, it should be noted that a 50% 3-year survival was obtained. A group was identified, using four prognostic factors that had 80% survival at 3 years. Maximum size of the residual tumor, as well as performance status, was not prognostically significant. This study demonstrates a lack of efficacy of the addition of C. parvum to melphalan for this patient population.

The canine laboratory in the training of the oncology fellow

This report deals with one fellow's experience in the dog lab established to aid in the surgical training of the gynecologic oncology fellow. The first experiment was designed to train the fellow in bowel resection and end-to-end anastomosis, comparing suture and staple techniques. A second study evaluated the physical and biological properties of polyglactin 910 (Vicryl) mesh to determine its applicability in reconstructing the pelvic floor following pelvic exenteration.

Vicryl mesh in pelvic floor reconstruction

A new synthetic absorbable mesh made of polyglactin 910 (Vicryl) fiber was used to reconstruct the pelvic floor in seven women undergoing pelvic exenteration. The technique is described. The follow-up ranged from three to 31 months and no patient developed a bowel problem. The material seems to be appropriate for this use, is completely absorbed, and acts as a latticework for the deposition of granulation tissue. The technique can be applied in patients requiring pelvic irradiation following surgery for malignant neoplasms of the gastrointestinal or genitourinary tracts. The small bowel is effectively held out of the pelvis and the radiation field, and is spared the effects of the radiation beam.

Mucin production in defining mixed carcinoma of the uterine cervix: a clinicopathologic study

Eighty-seven Stage 1 cervical carcinomas treated by radical hysterectomy between 1970 and 1979 were reviewed for histologic type, outcome, and factors predicting behavior. Initially, the cases were histologically classified by the Wentz and Reagan system and graded according to the Broders method. Stains for intracellular mucin were then examined in 69 cases and 39% were shown to contain intracellular mucin. Using intracellular mucin as an indicator of mixed carcinoma, this study showed a distribution of 35% keratinizing, 16% nonkeratinizing, 3% small cell, 16% adeno-, 3% undifferentiated, and 26% mixed carcinoma. The mixed carcinomas were derived from the traditional keratinizing, nonkeratinizing and small cell categories. Mixed carcinoma was the only histologic type that predicted lymph node metastasis (p = 0.009). The presence of lymph node metastasis predicted death due to disease or recurrence (p = 0.014) as did pure adenocarcinoma histology (p = 0.025). Overall 5 year survival was 92%. Survival at 5 years for adenocarcinoma was 85%, but one additional death occurred at 12 years and a first recurrence occurred at 7 years. An additional patient with a collision tumor (adenocarcinoma and squamous carcinoma) died at 8 years. Mixed carcinoma is relatively common and appears to be associated with a higher incidence of lymph node metastasis. Adenocarcinoma appears to have a poorer prognosis and a tendency for late recurrence in distant sites.

A randomized clinical trial of adjuvant adriamycin in uterine sarcomas: a Gynecologic Oncology Group Study

After hysterectomy, 156 evaluable patients with stage I (limited to the corpus) or stage II (limited to the corpus and cervix) uterine sarcomas were randomly assigned to adjuvant chemotherapy with Adriamycin (Adria Laboratories, Columbus, Ohio) for six months or to no further treatment. Pelvic irradiation (external or intracavitary) was optional before randomization. Of 75 patients receiving Adriamycin, 31 have suffered recurrences compared with 43 of 81 receiving no adjuvant chemotherapy. This difference is not statistically significant. Moreover, there is no difference in progression-free interval or survival. The optional radiotherapy did not influence the outcome although there was a suggestion that vaginal recurrence was decreased by pelvic radiotherapy. The recurrence rates in specific cell types (leiomyosarcoma, homologous mixed mesodermal sarcoma, or heterologous mixed mesodermal sarcoma) were not significantly different although the pattern of recurrence differed, with pulmonary metastases being more common in leiomyosarcoma and extrapulmonary recurrence being more common in mixed mesodermal sarcoma. The outcome with respect to chemotherapy was not altered even after adjusting for maldistribution of cases. Thus, we could not show a benefit for this dose schedule of Adriamycin as adjuvant treatment for uterine sarcomas.

Prevalence of papillomarvirus infection in colposcopically directed cervical biopsy specimens in 1972 and 1982

A total of 1264 consecutive cervical biopsy specimens obtained at the Parkland Memorial Hospital Dysplasia Clinic during 1972 were reviewed. Histopathologic specimens were assessed with special reference to changes induced by human papillomavirus. In 1972, only 0.7% of biopsy specimens were reported as consistent with human papillomavirus infection. Upon review, however, 36.5% of these specimens were found to demonstrate histologic criteria for the diagnosis of human papillomavirus infection. Approximately half of biopsy specimens reclassified as human papillomavirus were originally interpreted as inflammation; the others were interpreted as cervical intraepithelial neoplasia. Patients with human papillomavirus infection were significantly younger than patients with cervical intraepithelial neoplasia (24.9 versus 30.2 years). These findings were compared with 965 cervical biopsy specimens obtained in 1982. Thirty-four percent of these biopsy specimens revealed human papillomavirus infection. These observations support the concept that human papillomavirus infection of the cervix is not a new entity but a previously unrecognized finding whose prevalence has been relatively stable over a 10-year period.

Staging and surgical evaluation of ovarian cancer

Ovarian carcinoma is the only female genital malignancy surgically staged. Appropriate preoperative roentgenographic, isotopic, and endoscopic studies can help define the spread of disease and the extent of surgery required. At surgery, the common sites of metastases--pelvic and para-aortic lymph nodes, diaphragm, serosal surfaces and omentum--should be examined and biopsied or excised. Total hysterectomy, bilateral salpingo-oophorectomy, and appendectomy should also be performed in patients with epithelial ovarian tumors. Evidence suggests that patients who have had optimal cytoreduction of the tumor (less than 1.5 cm) have a better outcome following chemotherapy. Patients who have no clinical or CT evidence of disease after a full course of chemotherapy should be explored to confirm disease status. Peritoneoscopy can be used as an interval procedure to assess response to treatment.

Effect of radiation on prostaglandin production by human bowel in vitro

The effect of gamma irradiation on the production of prostaglandins by human colon was investigated. Squares of tissue in organ culture dishes were irradiated with 500, 1000, or 2500 rad in single applications. Tissues that were not irradiated served as controls. After treatment the tissues were superfused and prostaglandin concentrations in the effluent fluid were determined. The rates of production of prostaglandins E2 and F2 alpha by irradiated tissues were significantly lower (p less than 0.05) than those of nonirradiated tissues. Neither the release of lactate dehydrogenase nor the rate of production of 13,14-dihydro-15-keto-prostaglandin F2 alpha were increased in the irradiated samples, suggesting that neither decreased cell viability nor increased prostaglandin metabolism accounted for the decreased prostaglandin production rates. We conclude that irradiation of the human colon in vitro results in an acute inhibition of prostaglandin synthesis. The cytoprotective nature of prostaglandins is discussed with regard to the possible pathophysiological significance of these findings.

Naproxen sodium vs. a combination of aspirin, phenacetin, caffeine and codeine phosphate for pain after major gynecologic surgery. A multicenter comparison

In this multicenter study a nonnarcotic analgesic available for moderate pain, naproxen sodium, 550 mg, was compared to a combination that is used extensively for moderate to severe pain, aspirin, phenacetin, caffeine and codeine phosphate (APC/C) (60 mg of codeine phosphate). Women with pain after major gynecologic surgery reported a similar pattern in pain reduction with the two medications except for a relatively sharper increase in pain intensity between four and six hours after administration of APC/C. A smaller number of patient complaints suggested that naproxen sodium was better tolerated than APC/C.

Pigskin xenograft as biologic dressing in radical vulvectomy

Wound infection and breakdown constitute the most common complication of radical vulvectomy and groin lymphadenectomy. The use of pigskin xenograft as biologic dressing when the skin edges cannot be closed primarily without tension after radical vulvectomy and groin lymphadenectomy is described. This technique allows for clean granulation tissue to develop early (within five to seven days) and seems to accelerate the healing process. Its use has been associated with early ambulation and rapid recovery as well as a shorter postoperative stay.

Adenoid cystic carcinoma of Bartholin's gland. Case report and review of the literature

A patient with adenoid cystic carcinoma of Bartholin's gland is reported and the literature relevant to this disease reviewed. The clinical presentation is characterized by a vulvar mass that has existed for a prolonged period prior to the onset of symptoms, usually infection, pain, and burning. Histologically the tumor is characterized by a cribriform pattern and perineural invasion. Electron microscopy confirms the epithelial nature of this lesion. Conclusions concerning therapy are presented, including emphasis on initial radical vulvectomy and the fact that the efficacy of routine lymphadenectomy and adjuvant radiotherapy has not been demonstrated.

Use of the bulbocavernosus muscle (Martius procedure) for repair of radiation-induced rectovaginal fistulas

Radiation-induced fistulas of the vagina are rare, occurring in only 1 of 3% of patients treated for cancer of the uterine cervix. Primary surgical repair of these fistulas is usually unsuccessful because the defect is a result of devascularization. This type of radiation injury results from endarteritis obliterans, and successful repair requires an accessory blood supply. From 1971 to 1980, the authors performed 14 Martius procedures on 12 patients with radiation-induced rectovaginal fistulas. Eleven patients had successful closure of their fistulas using this procedure, and no operative complications occurred. The Martius procedure is effective for most radiation-induced vaginal fistulas, and the operation is well tolerated by most patients.

Primary epidermoid carcinoma of the vulva

During a 12 year period, 102 patients with invasive epidermoid carcinoma of the vulva were treated at the University of Iowa Hospitals and Clinic. The over-all corrected three year survival rate was 65.5 per cent, or 67 of 102 patients. Those treated by radical vulvectomy and bilateral dissection of groin nodes had a three year survival rate of 76.9 per cent, or 40 of 52 patients, while those treated by radiotherapy had a survival rate of 10 per cent, or two of 20 patients. Those with Stage I disease lesions, less than 1 centimeter in diameter, had an excellent survival rate whether they were treated by vulvectomy only or by radical vulvectomy with groin node dissection. Our experience in this selected group of patients would indicate that a degree of individualization in the treatment of early invasive lesions of the vulva can give most satisfactory results.

Plasma prostaglandin levels in radiation-induced enteritis

Increased prostaglandin synthesis has been implicated as a causative factor in the production of radiation induced enteritis. Seventeen patients selected to begin pelvic irradiation for treatment of gynecological cancer had plasma Prostaglandin E, Prostaglandin F, and 13, 14 dihydro 15 keto PGF2 alpha metabolite determined by radioimmunoassay, prior to initiation of radiotherapy, at weekly intervals during treatment and at six weeks following completion of radiotherapy. A total of 362 prostaglandin determinations were performed. Thirteen patients (76%) developed significant diarrhea consisting of three or more watery bowel movements per day. Nine patients (53%) had intermittent colicky pain and six patients (35%) had nausea and vomiting during treatment. Statistical evaluation revealed no significant elevation of plasma prostaglandins during radiotherapy.

Primary clear cell adenocarcinoma of the fallopian tube: light microscopic and ultrastructural findings

The first reported case of primary clear cell adenocarcinoma of the fallopian tube is presented. The patient, a 52-year-old female, was post-menopausal and presented with anemia and a pelvic mass. The presence of this histologic type in the fallopian tube is consistent with the mullerian origin of this tumor.

Pelvic exenteration for vulvovaginal carcinoma

Between 1964 and 1978, 16 pelvic exenterations were performed for advanced and recurrent vulvovaginal carcinoma. Eight patients had Stage III carcinoma and four had recurrent vulvar carcinoma. Ten patients had involvement of the anus/sphincter, and two had involvement of the proximal half of the urethra. There were four patients with vaginal carcinoma. Two patients with recurrent vaginal carcinoma had bladder/urethral involvement; one patient each with primary vaginal carcinoma had rectovaginal and vesicovaginal septal disease. Seven patients are alive and free of disease--six for more than 5 years and one for 4 years and 4 months. Three patients died, free of disease, one each of cerebrovascular accident, traumatic subdural hematoma, and pulmonary embolus. One patient died on the ninth postoperative day of aspiration pneumonitis. The absolute 5-year survival rate is 54%.

Intestinal fistula and obstruction following pelvic exenteration

Intestinal fistulas and obstruction are the most common and most serious complication of pelvic exenteration for gynecologic cancer. In a series of 58 patients, early intestinal fistulas developed in seven and late fistulas in 13 of the patients. Early fistulas are more commonly secondary to surgical trauma or technical errors and were noted to occur more frequently in patients who had previously undergone irradiation. Late fistulas are usually associated with intestinal obstruction and with a high incidence of recurrent malignant growth. The management of choice for intestinal fistulas following pelvic exenteration appears to be prompt surgical intervention with bypass procedures in preference to intestinal resections. Although several technical modifications have been applied to the exenterative operation with a trend toward a decrease in early obstruction and fistula formation rate, additional technical efforts will be necessary if these problems are to be solved.

Scalene node biopsy in advanced carcinoma of the cervix uteri

To determine the incidence of scalene node metastasis from carcinoma of the cervix uteri, all patients with advanced carcinoma of the cervix who underwent scalene node biopsy as part of a pretreatment evaluation at the University of Iowa Hospitals and Clinics have been reviewed. In 40 patients, left scalene node biopsy was indicated because of (1) metastatic para-aortic nodes (25); (2) palpable scalene nodes (2); and (3) other evidence of metastasis or unresectability. Of the 25 patients with metastasis to para-aortic nodes, seven (28%) had metastasis to the scalene node. None of these was palpable preoperatively. Because scalene node involvement indicates that the disease is beyond the scope of both surgical and radiation treatment, routine scalene node biopsy is recommended in those patients with para-aortic node metastasis.

Primary squamous cell carcinoma of the endometrium

Primary squamous cell carcinoma of the endometrium is extremely rare. The 21st case of this lesion that meets Fluhmann's criteria is presented. The histogenesis of this lesion remains unclear. The etiology of squamous cell changes in the endometrium is presented, and the prognostic implication of malignant squamous cells in endometrial carcinoma is discussed.

Treatment of carcinoma in situ of the vulva with topical 5-fluorouracil

Topical 5-fluorouracil (5-FU) has been suggested as a simple and effective approach to the treatment of carcinoma in situ of the vulva. In this study, 12 patients with carcinoma in situ of the vulva were evaluated and treated with topical 5-FU. Satisfactory results were obtained in 2. The nonresponders have subsequently undergone surgical therapy. Follow-up to date has been 9 to 96 months (average 38 months). The value of topical 5-FU in the treatment of carcinoma in situ of the vulva seems to be limited. Its use in vulvar neoplasia is discussed.

Intraarterial pelvic infusion chemotherapy in advanced gynecologic cancer

Fourteen patients with advanced localized gynecologic cancer were treated with 44 courses of intraarterial pelvic infusion chemotherapy. All patients received methotrexate with folinic acid rescue; 9 patients also received vincristine. Tumor regression was observed in 3 of 14 patients (21.4%). In 5 patients there were major complications related to 28 intraarterial catheter placements. Two patients developed leukopenia following chemotherapy. The value of intraarterial infusion chemotherapy in gynecologic cancer is limited. Its use in gynecologic oncology is discussed.

Pyometra complicating radiation therapy of uterine malignancy

This report concerns our experience with the clinical management of pyometra in 12 patients receiving radiation therapy at the University of Iowa Hospitals and Clinics for uterine epithelial malignancy. The effect of pyometra on radiation therapy is discussed. Adequate drainage is imperative, and appropriate cultures should be obtained. External radiation therapy may be continued as planned; however, intracavitary radium applications should be deferred.