Multisite gynecologic endometrioid adenocarcinomas: Can mutation profiling be used to distinguish synchronous primary cancers from metastases?

It is well recognized that some patients with endometrioid gynecological cancers have tumors arising in multiple sites (ovary, endometrium, and endometriosis) at the time of diagnosis. Molecular analysis has helped discern whether these multisite cancers represent synchronous primary tumors or alternatively metastatic disease. We present a complex case of a patient with endometrioid carcinomas arising in multiple sites. We discuss the use of mutation profiling to discern clonality and highlight how this information may inform the clinical management of such cases.

The prognostic effects of performance status and quality of life scores on progression-free survival and overall survival in advanced ovarian cancer

OBJECTIVE

Performance status (PS) is an important prognostic factor in advanced ovarian cancer. The purpose of this study was to evaluate the prognostic significance of PS and quality of life (QoL) assessment on progression-free survival (PFS) and overall survival (OS) in patients with advanced ovarian cancer.

METHODS

We studied Canadian patients participating in an intergroup study in ovarian cancer (NCIC-OV10), which randomized patients to receive either standard chemotherapy using cisplatin/cyclophosphamide or cisplatin/paclitaxel chemotherapy. QoL was assessed using the EORTC quality of life questionnaire (QLQ-C30+3). The effects of multiple variables including the relevant clinical variables, PS and QoL scores were analyzed by Cox stepwise regression at baseline and again 3 months after completion of chemotherapy.

RESULTS

At baseline and at 3 months after chemotherapy, there were 151 and 93 patients respectively who completed the QLQ-C30+3 questionnaires. Baseline PS, global QoL score and treatment were independent predictors for both PFS and OS. Baseline cognitive functioning score was also an additional independent predictor for OS. At 3 months after completion of chemotherapy global QoL score, PS and grade were significant independent predictors of OS; however, only physical functioning score, emotional functioning score and tumor grade predicted for PFS.

CONCLUSIONS

Performance status and global quality of life scores at baseline are prognostic factors in advanced ovarian cancer for both PFS and OS. Higher baseline cognitive functioning scores were also associated with improved survival. Global QoL scores at 3 following completion of chemotherapy proved to be of prognostic significance for OS but not PFS.

Management of aggressive histologic variants of endometrial carcinoma at the Tom Baker Cancer Centre between 1984 and 1994

OBJECTIVE

The aim of this study was to determine the patient characteristics and outcome of patients with aggressive histologic variants (AV) of endometrial carcinoma, including uterine papillary serous carcinoma (UPSC), uterine clear cell carcinoma (UCCC), and mixed type.

METHODS AND MATERIALS

All cases with AV histological type of endometrial carcinoma from January 1984 to December 1994 at the Tom Baker Cancer Centre were identified using the Alberta Cancer Registry. Relevant data from the charts of these patients were entered into a study database (Microsoft Excel) and analyzed for presentation, demography, treatment parameters, and outcome of treatment. All pathology was reviewed at the time of diagnosis. Statistical analysis was performed using the S-plus statistics computer program. Univariate and multivariate analyses were used to assess independent prognostic factors using the Cox proportional hazards model.

RESULTS

A total of 103 patients with AV histological type were identified and analyzed; there were 61, 31, and 11 cases of UPSC, CCC, and mixed tumors, respectively. Sixty-three patients had Stage I, 11 had Stage II, 15 had Stage III, and 14 had Stage IV disease. The median age of patients was 67 years with a range of 36 to 86 years. Median follow-up was 60 months with a range of 36 to 156 months. The Cox proportional hazards model showed that lymphvascular space invasion and stage are the two independent prognostic factors affecting recurrence and survival. Forty six percent of all cases underwent surgery alone, 39% underwent treatment which included pelvic RT, and 17% underwent treatment which included chemotherapy. Pelvic recurrence was reduced significantly by radiotherapy in Stages I, II, and III (19% recurrence with no RT vs 7% recurrence with RT, P < 0.005). Chemotherapy improved overall survival, but made little difference in distant relapse rates.

CONCLUSIONS

Stage Ia cases treated by surgery alone have a low risk of relapse and need not be offered adjuvant systemic therapy or pelvic radiation. Patients with Ib, Ic, II, and III have significantly lower pelvic failure rates if treated with pelvic radiation, but still have a high distant failure rate. Systemic therapy did not significantly improve distant relapse-free survival, but did extend overall survival. Stage IV patients usually died within 6 months with a few responding to systemic chemotherapy. These results suggest that there is a need for randomized trials for these patients.

Intergroup collaboration in ovarian cancer: a giant step forward

The rather slow evolution of so-called "optimal chemotherapy" for ovarian cancer is the result of suboptimal randomised clinical trials, not having the statistical power to identify truly superior regimens, and of the lack of systematic comparisons of new agents with relevant control arms. There is little doubt that we need international collaboration to move the field forward in a timely and coherent manner. European and transatlantic collaboration represents the beginning of the process and point to the success that can await us if the drive to work together remains strong. A similar organisation as for breast cancer (Breast International Group, BIG) needs to be established for ovarian cancer.

The natural history of CIN I lesions

The published literature indicates 11% of CIN I lesions on average progress to a higher grade dysplasia and the remainder either regress or persist. Reliable markers of disease outcome are yet to be identified. A longitudinal study of 342 women referred for colposcopic examination of a CIN I detected by a screening Pap test, and classified by the colposcopic impression and Pap test at that exam as </= CIN 1 was designed to identify predictors of disease outcome. The cohort was comprised of 220 women who satisfactorily completed the study and whose disease was neither biopsied or treated at the initial examination. All had HPV DNA testing by PCR, and were followed with interval colposcopic examinations and repeat Pap tests for a limited time period. The initial HPV DNA status and a number of measured clinico-pathological and risk factor variables were analyzed to identify outcome predictors. All underwent a biopsy either at the conclusion of the study or because their disease was considered to have progressed during the follow up period. Biopsy confirmed progression to CIN II/III occurred in 41 (18.6%), persistence of CIN I/Condyloma in 41 (18.6%), and regression to <CIN I/Condyloma in 138 (62.7%). HPV DNA positivity and current, oral contraceptive use were the only independent predictors of progression when age at diagnosis, the number of follow up visits, and time to progression were controlled. Predictors of persistent and regressed disease were not identified. The study highlights a clinical role for HPV testing in the colposcopic management of CIN I lesions. Oral contraceptives may promote progression by regulating the oncogenic sequences of the HPV.

Predictors of co-incidental CIN II/III amongst a cohort of women with CIN I detected by a screening Pap test

Approximately 20-40% of lesions interpreted by a screening Pap test as CIN I and subsequently examined by colposcopy include a co-incidental CIN II/III. Since the HPV profiles of CIN I and CIN II/III differ, HPV typing may predict these co-incidental higher grade lesions. Based on both the colposcopic impression and repeat Pap test, 537 women referred for examination of CIN I as classified by a screening Pap test were triaged into group A (</= CIN I) or group B (>/= CIN II). Clinical, demographic, reproductive, and risk factor data was collected by questionnaire and HPV typing of cervical scrapes was done by PCR. Group A included 342 (63.7%) women and group B 195 (36.3%). Group B women more frequently were current cigarette smokers (p<0.001) and had a high school or lesser level of education (p=0.04). HPV positivity amongst younger group B women (</= 21 years) and a history of current/occasional cigarette smoking in those 22 years and older were significant predictors of triaged, co-incidental CIN II/III (p<0.001). This age restriction will limit the adoption of HPV testing as an universal, adjunctive test for the identification of CIN II/III amongst CIN I lesions detected by a screening Pap test. A greater health advantage may be gained by increasing women's awareness of the risks, including that of cervical cancer associated with cigarette smoking.

Review of the screening history of Alberta women with invasive cervical cancer

OBJECTIVE

To conduct a failure analysis of cervical cancer screening among women with invasive cervical cancer in Alberta.

DESIGN

Descriptive study. Review of demographic, staging and treatment information from cancer registry records; generation of documented screening history from Alberta Health billing records and self-reported history from subjects who agreed to be interviewed; and comparison of findings in initial cytology reports with those from subsequent review by at least 2 pathologists of all cytology slides for each patient for the 5 years before diagnosis. Cases were assigned to 1 of 6 categories of identified screening failure.

SETTING

Alberta.

SUBJECTS

All women with diagnosis of invasive cervical cancer reported to a population-based provincial cancer registry from January 1990 to December 1991.

OUTCOME MEASURES

Demographic, staging and treatment information; documented and self-reported screening histories; correlation of test results in initial cytology report with those generated from slide review; category of identified screening failure.

RESULTS

Of the 246 women identified with invasive cancer of the cervix, 37 (15.0%) had stage IA disease; 195 (79.3%) had squamous-cell carcinoma, and 35 (14.2%) had adenocarcinoma. According to the categories of screening failure, 74 women (30.1%) had never been screened, 38 (15.4% had not been screened within 3 years before diagnosis, 42 (17.1%) had had a false-negative cytology result, and 20 (8.1%) had been managed outside of conventional protocols. Of the 23 women (9.3%) who had been screened appropriately and had true-negative results, 19 had smears that were considered technically limited. It was not possible to classify 49 (19.9%) of the cases. Agreement between the documented and the self-reported screening histories was exact for only 39 (36.1%) of the 108 women interviewed.

CONCLUSIONS

Despite widespread use of opportunistic cervical screening, many women in Alberta are still not being screened adequately. In most cases women are being screened too infrequently or not at all. Self-reported screening histories are unreliable because many women may overestimate the number of smears. An organized approach to screening, as recommended by the National Workshop in Cervical Cancer Screening, may assist in reducing the incidence of invasive cervical cancer.

Risk-specific follow-up for endometrial carcinoma patients

OBJECTIVE

To propose a risk-specific follow-up protocol for endometrial carcinoma patients.

METHODS

A retrospective cohort of endometrial carcinoma patients was used to identify risk factors for recurrence. Based on a profile of risk factors, women were classified at either low or high risk for recurrence (median follow-up 70 months). The classification system was validated on a subsequent cohort.

RESULTS

Surgical stage, grade, and histology were found to be significant predictors (P < 0.001) of recurrence. In the original cohort, patients with stage Ia, grade 1 or 2, or stage Ib, grade 1 adenocarcinoma, had a recurrence rate of 4/98 (4.1%). The remaining high-risk patients had a recurrence rate of 37/158 (23.4%). When applied to the subsequent cohort, the rates were similar: low risk 3/113 (2.7%) and high risk 30/140 (21.4%). Seventy-five percent of recurrences occurred within 3 years of diagnosis and the majority were heralded by site-specific symptoms.

CONCLUSIONS

Women with endometrial carcinoma can be successfully classified for low or high risk of recurrence. It is proposed that low-risk patients not be maintained on routine follow-up and that a tailored schedule of follow-up be used for high-risk patients. These changes would serve patients more appropriately and use health care resources more efficiently.

The HPV determinants of CIN I

Correlates of HPV amongst a cohort of women with a CIN I detected by a screening Pap test were investigated. Co-incident CIN II/III lesions were identified and their influence on the HPV status and HPV determinants of screening detected CIN I was assessed. Based on both the colposcopic impression and repeat Pap test, 537 women referred for examination of a Pap test classified as CIN I were triaged into two groups. Group A lesions were assessed as </= CIN I; n = 342 (63.7%) and group B as >/= CIN II; n = 195 (36.3%). Clinical, demographic, reproductive, and risk factor for cervical cancer correlates were collected. HPV typing of cervical scrapes collected at the colposcopic examination was done by PCR amplification using seven sets of type specific and one set of consensus primers. HPV positivity was identified in 47% of all scrapes; types 16/18 (28%), 31/33/35 (10%), 6/11 (2%), and unknown (7%). The HPV status of the cohort and group A were very similar. Group B had a slightly higher rate of HPV positivity (52%) due to an increase in types 16/18. Statistically significant correlates of HPV prevalence or type were not identified either for the entire group or both triage groups, however in each group, HPV positive women tended to be younger and to have more sexual partners. Co-incident CIN II/III spuriously increased the HPV prevalence rate of CIN I detected by a screening Pap test. The HPV appears to be sexually transmitted both in low and high grade lesions and explains why the HPV determinants of the entire cohort were unaffected by the co-incident CIN II/III.

Spontaneous rupture of the urinary bladder: a late complication of radiotherapy--case report and review of the literature

The spontaneous intraperitoneal rupture of the urinary bladder is an extremely rare life-threatening event. There are often difficulties in establishing the diagnosis. A patient with spontaneous perforation of the urinary bladder, 15 years after pelvic radiotherapy for carcinoma of the cervix is reported. Aspects of etiology, clinical presentation, diagnosis, and management are described. Special emphasis is placed on surgical management as it relates to long-term outcome.

Phase II study to evaluate the toxicity and efficacy of concurrent cisplatin and radiation therapy in the treatment of patients with locally advanced squamous cell carcinoma of the cervix

Sixty patients presenting with poor prognosis squamous cell cancer of the cervix have been studied in a phase II clinical trial. Patients were treated with radiotherapy and concurrent cisplatin chemotherapy every 10 days. Treatment was well tolerated with all patients completing radiotherapy as prescribed. There was one case of grade 4 acute bowel toxicity. Significant late morbidity was acceptable for this group of patients being restricted to two cases (3.3%) of grade 4 toxicity to the bowel. Pelvic control rates of 78% have been observed. There have been no pelvic recurrences after 26 months, although recurrences beyond the pelvis have occurred up to 4 years later. Actuarial 4-year survival is encouraging at 60%.

The human papillomavirus status of invasive cervical adenocarcinoma: a clinicopathological and outcome analysis

Accumulating evidence highlights the human papillomavirus (HPV) as a risk factor for cervical adenocarcinoma. However, the part played by the HPV in predicting tumor outcome or the increasing frequency of cervical adenocarcinoma is incompletely studied. In a retrospective study the association between HPV status and the clinicopathological characteristics of 77 cases of cervical adenocarcinoma was investigated. The data were then analyzed for temporal differences in HPV status and to identify outcome predictors. Human papillomavirus status was determined by dot blot hybridization using probes for HPV 6, 11, 16, 18, 31, 33, and 35, followed by polymerase chain reaction amplification of the dot blot negative cases. Seven type-specific and consensus HPV primers were used. Human papillomavirus type 16, 18, or 33 was present in 53 (70%) cases. Human papillomavirus status did not correlate with disease outcome or any clinicopathological variable, except that tumors presenting in and after 1981 were more frequently HPV positive than those presenting before 1981 (P = .014). In a multivariate analysis only clinical stage at presentation was predictive of disease outcome. Because temporal differences in clinicopathological characteristics were not identified, the increasing frequency of cervical adenocarcinoma may relate to a more important oncogenic role for the HPV in tumors presenting after 1980.

Uterine atypical polypoid adenomyoma and ovarian endometrioid carcinoma: metastatic disease or dual primaries?

Atypical polypoid adenomyoma (APA) is an uncommon uterine tumor that rarely metastasizes, although it closely resembles a well-differentiated endometrioid carcinoma. A 37-year-old woman with a history of pelvic endometriosis and oral contraceptive use developed an APA and later presented with bilateral ovarian endometrioid carcinomas. DNA ploidy analysis and human papilloma virus (HPV) typing of the APA and ovarian carcinomas were performed to characterize the primary or metastatic nature of the tumors. Both tumors were aneuploid. The APA had a DNA index of 1.53, compared with 1.19 for the ovarian carcinoma. The APA contained HPV 18, and the ovarian carcinoma a mixed infection of HPV 6, 11, 16, and 18, with types 6 and 11 predominating. These differences in DNA index and HPV type supported the autonomous nature of the APA and the ovarian carcinomas. The report affirms the benign outcome of APA, highlights its complication by a second malignancy, and suggests an etiological role for endometriosis, steroid hormones, and possibly the HPV in the formation of one or both tumors.

An evaluation of routine follow-up of patients treated for endometrial carcinoma

This retrospective review evaluates the outcome benefit of a standard follow-up protocol for 435 patients treated for endometrial carcinoma between 1981 and 1986. Routine follow-ups consisting of physical examinations and vaginal cytologies were done every 3 months for the first year, 4 months for the second year, and 6 months thereafter. Chest X rays were done biannually. Demographic, histopathologic, therapeutic, and follow-up data were studied. Exclusions due to incomplete follow-up (70), persistent disease (40), or other primary malignancies (8) left 317 patients with a disease-free state assigned to follow-up. Recurrences developed in 53 patients being followed, 40 (75%) of whom were symptomatic. Family physicians primarily diagnosed recurrences in 34 patients while recurrences in only 11 of the 53 patients (21%) were detected on routine follow-up at the cancer center (5 by examination and 6 by chest X ray). Therefore, only one recurrence was detected for every 206 routine follow-up visits. Vaginal vault cytology was not diagnostic in any patient. Seventy percent of recurrences occurred within 3 years. There was no statistical difference in survival between the group detected on routine follow-up and those who were symptomatic (P = 0.55). Routine follow-up of patients treated for endometrial cancer did not improve detection of recurrences or survival.

Adenocarcinoma in situ of the endocervix: human papillomavirus determination by dot blot hybridization and polymerase chain reaction amplification

The frequency of human papillomavirus (HPV) in series of endocervical adenocarcinoma in situ (AIS) ranges from 6 to 100%. Some of this variability can be attributed to small study numbers and such technical considerations as the sensitivity of the hybridization method employed. Consequently, the role of the HPV in AIS oncogenesis is unclear. The frequency and relative distribution of HPV DNA types 6, 11, 16, 18, 31, 33, and 35 in 37 cases of AIS were determined and correlated with clinical variables. All cases were first typed by dot blot hybridization (DBH), and those found to be HPV negative were subsequently typed by polymerase chain reaction amplification with DBH enhancement (PCR/DBH). The HPV DNA positivity rate was 27% by DBH alone and 52% by PCR/DBH amplification. Combining the results of both methods, the overall HPV positivity rate was 66%: HPV 18 in 15 cases (43%), HPV 16 in eight cases (23%). The HPV status did not correlate with any clinical variable. This study showed that the sensitivity of the hybridization method is principally accountable for the variable frequency of HPV in AIS. The identification of only high-risk oncogenic HPV types in two-thirds of the cases suggests a significant role for the virus in AIS oncogenesis; HPV status, however, does not delineate a clinical profile.

Carcinoma of the cervix following conservative management of cervical intraepithelial neoplasia

The purpose of this study was to identify the reasons for treatment failures in patients managed with cervical intraepithelial neoplasia who subsequently developed invasive carcinoma of the cervix. Of 672 patients seen with cervical carcinoma from 1980 to 1990 inclusive, at the Tom Baker Cancer Centre, 24 (3.6%) had previously undergone conservative treatment for CIN and represent the current study population. The initial colposcopic-guided biopsy showed metaplasia (2), CIN 2 (5), and CIN 3 (17). The conservative treatment methods included observation (5), electrocautery (1), laser ablation (3), surgical cone (5), and cryotherapy (10). The mean time interval in months from conservative treatment of CIN to diagnosis of cervical cancer was 21.8 with cryotherapy and 26.7 with laser ablation. The FIGO stage of invasive cervical cancer was Stage 1A (7), Stage 1B (15), Stage 2A (1), and Stage 3 (1). The single death was a patient aged 30 with metastatic small cell cervical carcinoma arising within 4 years of cryotherapy for CIN 3. Of the 24 patients, 13 were managed appropriately yet developed carcinoma, 3 deviated from an accepted standard colposcopy protocol, 5 had inadequate follow-up, 2 refused treatment, and 1 developed de novo disease. The principle reason for treatment failure according to the literature is blatant deviation from protocol. This study, however, suggests that established invasive disease may have gone undetected prior to an ablative therapy. Difficulties related to diagnosis are discussed. The importance of peer reviews becomes evident if practices are to be evaluated and changes to protocols are to be implemented.

Estrogen and progesterone receptor, human papillomavirus, and DNA ploidy analysis in invasive carcinoma of the cervix in pregnancy

From 1980 to 1991, 13 patients had pregnancy-associated invasive carcinoma of the cervix: four carcinomas were stage IA; eight were stage IB; and one was stage IVB. Gestational ages range from 8 weeks to 3 months postpartum. Two patients are dead of disease and a third is alive with metastases. Results of immunoenzyme studies for estrogen receptors (ER) were variably positive in all except one tumor, whereas results of studies for progesterone receptors (PR) were uniformly negative. Thus, these hormone receptor studies are unlikely to be of prognostic significance. Six tumors contained human papillomavirus (HPV) DNA by in situ or dot blot hybridization (three, HPV 16; two, HPV 18; one, HPV 31/33/35). Thus, neither ER nor PR expression appears to be related to the infecting HPV type. Using flow cytometry, three tumors were determined to be aneuploid and a fourth, tetraploid. To correlate HPV or DNA flow cytometry data with prognosis will require study of larger numbers of patients from multiple centres.

Intraperitoneal interferon in the management of malignant ascites

BACKGROUND

Ascites secondary to malignancy is a major cause of recurring morbidity in patients with ovarian cancer. In patients previously treated with cisplatin, other chemotherapeutic agents are not likely to be effective in relieving symptoms.

METHODS

A pilot group of ten patients was treated with intraperitoneal alpha-2B-interferon (alpha-2B-IFN) in an effort to provide symptomatic relief of their ascites. All patients had advanced epithelial ovarian cancer at the time of therapy and were receiving treatment for palliation only. Symptoms included abdominal distention (100% of patients), nausea and vomiting in the absence of mechanical intestinal obstruction (60%), and dyspepsia (40%).

RESULTS

At a dose of 10 M units/m2 given intraperitoneally every 2 weeks for one to four treatments, the toxicity was low, but the benefits were minimal. Five (50%) patients reported symptomatic improvement of 2-7 weeks' duration. The most common side effects included fever (temperature of more than 38.5 degrees C) and abdominal pain.

CONCLUSIONS

At the dose of 10 M units/m2 of intraperitoneal alpha-2B-IFN, this regimen did not appear to produce clinically significant palliation of the ascites in most patients.

Outpatient laser cone biopsy under local anesthesia

The authors report on 60 patients who had abnormal findings on cervical cytologic examination, necessitating conization of the cervix. The procedure was done in an ambulatory setting, with a carbon-dioxide laser unit and local anesthesia. The average operative time was 16.9 minutes. Fifty-one (85%) patients experienced no complications, and there were no cases of excessive bleeding. In all patients, the specimen was satisfactory for histologic review. Only 5% (three) of patients would have preferred to have the procedure performed under general anesthesia. Laser cone biopsy of the cervix can be performed in an outpatient setting, with local anesthesia. Morbidity is minimal and there is potential for economic saving when compared with conventional methods for biopsy of the cervix.

The human papillomavirus status of 114 endocervical adenocarcinoma cases by dot blot hybridization

The reported rate of human papillomavirus (HPV) positivity in cases of endocervical adenocarcinoma averages 38% (range, 0% to 100%) and, in contrast to cervical squamous cell carcinoma, HPV type 18 rather than type 16 is the predominant type. The HPV positivity rate and distribution of types (status) in 114 endocervical adenocarcinoma cases (37 in situ and 77 invasive) were determined by dot blot hybridization using biotinylated probes to HPV types 6, 11, 16, 18, 31, 33, and 35. Human papillomavirus DNA was present in 27% of in situ and in 44% of invasive adenocarcinomas, and in nearly all histologic subtypes of invasive adenocarcinoma. Human papillomavirus status was not predictive of tumor grade, volume, depth of invasion, lymph-vascular space involvement, age at presentation, or year of diagnosis. Type of HPV might influence the histologic subtype of invasive adenocarcinoma, as HPV type 16 predominated in the adenosquamous carcinomas while HPV type 18 was more frequently found in all other subtypes. Since only types 16, 18, and 33 were identified, an oncogenic role for HPV in endocervical carcinogenesis was supported.

Laser therapy of vulvar lichen sclerosus et atrophicus

Seven patients with a histologic diagnosis of lichen sclerosus et atrophicus of the vulva were treated by laser ablation of the affected area to a depth of 1.0 to 2.0 mm. The inpatient procedure was performed under general anesthesia with a carbon dioxide laser unit. Healing was complete 6 weeks postoperatively. All but one patient was free of recurrent symptoms at follow-up, which ranged from 12 to 37 months. Laser ablation is an acceptable treatment for patients who have symptoms due to lichen sclerosus of the vulva that are refractory to other measures.

Cervico-vaginal screening in an STD clinic

From May 1986 to March 1988, there were 3,622 "new" female clients at the Calgary Sexually Transmitted Disease (STD) Clinic of whom 2,278 registered for the first time. A cervico-vaginal (Pap) smear was obtained from those who had not had one in the previous 6 to 12 months and any history of venereal warts (VW) was recorded. 621 smears were accessed of which 611 were suitable for inclusion in this study. 65 (10.6%) smears revealed human papillomavirus (HPV) and/or cervical intraepithelial neoplasia (CIN). Any history of VW increased the likelihood of an abnormal smear by 5.3 times. Those with currently visible VW were more likely (8.8 times) to have an abnormal smear than those with a past history (3.5 times). These data re-affirm the recommendation of the first "Walton Report" that Pap smears should be obtained in STD Clinics.

Evaluation of surgical staging in stage I low malignant potential ovarian tumors

The charts and pathology specimens of 27 patients with ovarian tumors of low malignant potential were reviewed in an attempt to document the rationale for a second laparotomy in those patients with clinical stage 1 disease and who did not have a complete staging laparotomy at their initial surgery. Four of 13 patients with serous tumors, none of 12 patients with mucinous tumors, and one patient with a mixed tumor of LMP were upstaged at the staging laparotomy. The major morbidity rate associated with the procedure was 7.4%. The low yield of a staging laparotomy in patients with mucinous tumors (0%) does not warrant a second operation. The higher yield of a staging laparotomy in patients with serious tumors (30.8%) suggests that the likelihood of upstaging the disease exceeds the potential morbidity, and for this reason, the procedure may be warranted. However, the specific role of a staging laparotomy even in those with serous tumors awaits further study of the prognostic significance of invasive versus noninvasive implants.

Malignant transformation occurring in mature cystic teratomas of the ovary

Two cases in which tumours of contrasting malignant potential arose in mature cystic teratomas (dermoid cysts) of the ovary are presented: one patient had a spindle-cell sarcoma and the other a trabecular carcinoid. The first patient's clinical course was characterized by rapid recurrence of the tumour and death 3 months after surgery. The second patient is alive and well with no evidence of residual carcinoid, although the follow-up time is short. Since the surgical procedure of choice differs substantially if malignant transformation occurs in an ovarian dermoid cyst, the pathologist should be consulted intraoperatively in selected cases.

Nonisotopic human papillomavirus DNA typing of cervical smears obtained at the initial colposcopic examination

To determine the prevalence of human papillomavirus (HPV) infection in 401 patients attending colposcopy for the first time, scraped cervical cells were investigated using dot blot hybridization and biotinylated DNA probes to HPV 6 and 11 (low-risk types) and 16, 18, and 33 (high-risk types). The HPV DNA was isolated from 52% of patients (low-risk types = 4%, high-risk types = 48%). Seventy-five percent had a cervical intraepithelial neoplasia (CIN)-condyloma. Low-risk types were infrequent (7%) and high-risk types (41%) predominant in condyloma/CIN I lesions when converse rates were expected. As CIN I lesions harboring high-risk types are at some risk of progressing to a higher grade dysplasia, colposcopic examination and treatment of this subgroup would seem justified. As expected, high-risk types were statistically associated with increasing grades of dysplasia. This hybridization method identified typeable HPV DNA in 60% of patients with a CIN-condyloma, and highlighted a unique HPV profile for this patient cohort.

Ependymoma of the uterosacral ligament

Extraspinal ependymomas have been described in the subcutaneous sacrococcygeal and presacral areas. Since 1984, eight pelvic ependymomas have been reported that have originated in the ovary, broad ligament, mesovarium, and omentum. This report documents an additional case arising from the right uterosacral ligament in a 48-year-old woman. The diagnosis of ependymoma was supported by a histologic pattern of true rosettes and pseudo-rosettes, glial fibrillary acidic protein (GFAP) positivity, and electron microscopic findings of cilia, blepharoplasts, and intermediate filaments. The tumor was positive for cytokeratin and vimentin. Ultrastructurally, neurosecretory granules were present within the cytoplasm. These features have not been described previously in pelvic ependymomas. These tumors, although easily confused with serous papillary carcinoma, should be distinguished from serous papillary carcinoma because of their apparently better prognosis and tendency for late recurrence.

Recurrent and persistent squamous cell cervical carcinoma in women under age 35

Forty-five patients with invasive cervical squamous cell carcinoma were registered in the Tom Baker Cancer Centre from 1980 to 1985. The natural history of 22 patients (48.9%) who developed persistent or recurrent disease including 11 Stage IB, 8 Stage IIB, and 3 Stage IIIB is reported. Only one patient who had the uncommon papillary variant is alive without evidence of residual disease. The remainder are either dead (16) or alive with residual disease (5). Four patients never achieved a disease-free status and in the remainder recurrences developed on average in 8.7 months. Central or regional disease was not controlled in 20 of 22 patients. Neither radical surgery nor radiotherapy was evidently more effective in preventing persistent or recurrent disease. A reliable predictive marker for persistent or recurrent disease is required: lymph-vascular invasion in the radical hysterectomy specimens was present in 5 of 6 cases but it is subject to interpretive error. Since the disease is frequently systemic at the time of diagnosis, early adjuvant therapy and improved staging techniques are required to improve the survival.

Laser vaporization of vaginal intraepithelial neoplasia

Laser vaporization was used to treat 27 women diagnosed at the Tom Baker Cancer Centre, Calgary, Alberta, Canada, as having vaginal intraepithelial neoplasia. The diagnosis was established after review of vaginal cytologic examination and a histologic biopsy. Treatment was performed with a carbon dioxide laser unit attached to an operating microscope. All but three patients had general anesthesia for the purpose of treatment. Tissue destruction was accomplished to a depth of 2 to 3 mm. Patients were followed up for an average of 14.4 months with regular colposcopy, cytologic evaluation, and biopsy when persistent or recurrent disease was suspected. Failure of therapy was defined as evidence of intraepithelial neoplasia in any one of these three parameters. Four patients required a second treatment. After one or two treatments the success rate of therapy was 78%. In our institution, laser vaporization with the patient under general anesthesia on an outpatient basis is the treatment of choice for vaginal intraepithelial neoplasia.

Invasive squamous cell carcinoma of the cervix in women less than 35 years old: recurrent versus nonrecurrent disease

Invasive cervical squamous cell carcinoma was diagnosed in 45 patients less than 35 years old from 1980 to 1985. Thirty-two cases were Stage IB; 10, Stage IIB; and three, Stage IIIB. Twenty-two patients developed persistent or recurrent disease. Only one of these is now alive with no evidence of tumor. The mean interval from diagnosis to recurrence was 8.7 months (median of 7.0) and from diagnosis to death was 14.7 months (median of 12.0). Eleven of 32 patients with Stage IB disease developed a recurrence; the intervals to recurrence in Stage IB disease were similar to those for more advanced stages. Factors predicting recurrence included advanced stage of the disease and tumor bulk (maximum size, depth of invasion, and number of involved quadrants) as well as an exophytic or ulcerative tumor and a symptomatic presentation. These factors may identify the patient at high risk for recurrence who would benefit from adjuvant therapy.

Endometrial carcinoma occurring in patients under the age of 45 years

Endometrial adenocarcinoma is frequently unsuspected in women under the age of 45 years by the gynecologist or the pathologist, but it does occur. Twenty-seven cases of endometrial adenocarcinoma in this age group, from 1980 to 1985, were reviewed clinically and pathologically. Five cases were excluded by histologic examination. Obesity and abnormal vaginal bleeding were shown to be risk factors. Endometrial screening is to be encouraged. This cancer may arise de novo rather than from a premalignant precursor. Implications of this neoplasm for the premenopausal woman are considered.

Inguinal intranodal blue nevus: a case report

Inguinal intranodal blue nevus is a rare lesion, but awareness of the condition will avoid a mistaken diagnosis of metastatic melanoma. The authors describe the case of a 40-year-old woman in whom an inguinal node blue nevus was discovered incidentally during radical vulvectomy for squamous cell carcinoma. They describe the characteristic light and electron microscopic features. With increased awareness of this lesion the authors believe it will be found in lymph-node chains other than the inguinal and axillary ones previously reported.

Development of ovarian carcinoma in a cyclosporin A immunosuppressed patient

This is the first report of an ovarian carcinoma developing in a patient immunosuppressed by Cyclosporin A. Thirteen months before the diagnosis of malignancy, the patient received a living related donor kidney transplant whose rejection was controlled by Cyclosporin A and prednisone. The tumor was rapidly fatal five weeks from diagnosis. The literature on malignant transformation in the immunosuppressed patient is reviewed with emphasis on a gynecologic perspective.

Ruptured benign cystic teratomas mimicking gynecologic malignancy

Ruptured benign cystic teratomas of the ovary mimicking gynecologic malignancy are uncommon, but frequently misdiagnosed. Two cases are reported that, preoperatively, were believed to represent ovarian carcinoma, but were found to have diffuse granulomatous peritonitis, secondary to perforation of the teratomas. Intra-abdominal adhesions and/or masses are frequent sequelae. A diagnosis of malignancy must be confirmed prior to performing radical surgery. A review of the literature is presented.

Carbon dioxide laser surgery

Lower genital tract intraepithelial neoplasia was the predominant indication for CO2 laser surgery in 203 patients treated at Wayne State University. One hundred nineteen patients had cervical intraepithelial neoplasia (CIN) III and, in the 99 patients who were adequately followed, the failure rate following the first treatment was 9%. Secondary treatment with laser surgery, cryosurgery or, in one instance, hysterectomy, was effective in treating all persistent CIN. Success in treating vaginal intraepithelial neoplasia with laser surgery was most favorable in patients who had not had prior pelvic irradiation. Small (less than 1.5 cm) vulvar intraepithelial neoplasia III was successfully treated in seven patients. Recalcitrant condyloma acuminata responded well to laser surgery in 31 patients.

The changing role of "second-look" laparotomy in the management of epithelial carcinoma of the ovary

Thirty-seven of 137 patients had a "second-look" laparotomy in the course of their management of carcinoma of the ovary. Patients were stratified according to three indications: (1) evaluation of disease with intent of stopping therapy, (2) assessment of signs of recurrent or persistent disease with a view to debulking tumor mass and changing chemotherapy, and (3) further tumor resection following cis-platinum combination therapy and determination of further chemotherapeutic agents. "Second-look" laparotomy may be performed after a shorter time interval when combination therapy is given because of the dose-limiting side effects of some of these agents and a more aggressive surgical approach in debulking tumors. At the time of laparotomy, cytologic testing is performed on the peritoneal fluid, and only areas suspicious for malignancy are biopsied. Thirteen percent of patients with no evidence of disease at "second-look" laparotomy developed recurrent disease. Twenty-nine percent of patients classified as clinically free of disease had malignancy present at the time of operation. Continued routine use of "second-look" laparotomy after appropriate chemotherapy is recommended.

Assessment of failures of cryosurgical treatment in cervical intraepithelial neoplasia

The overall recurrence rate in 166 patients treated with cryosurgery is 10.8%. Recurrent cervical intraepithelial neoplasia is much more common in patients with severe dysplasia. Failures are commonly due to one of four factors. First, cryosurgery is to be used only after adequate colposcopic assessment and a negative endocervical curettage. Cryosurgery is a safe, effective treatment in selected patients, but consideration of surgical management should be given in the older patient who has completed childbearing, particularly those with severe dysplasia or carcinoma in situ. A full 7-minute freeze with optimum application of the cryoprobe to the full affected surface is essential. Careful follow-up of these patients is mandatory. The majority of failures occur within the first 12 months and probably represent persistent rather than recurrent diseases.

Squamous cell carcinoma of the vagina following hysterectomy

A retrospective analysis of 29 cases of squamous cell neoplasia of the vagina following hysterectomy is presented. Two groups of patients were identified; the first presented following hysterectomy for cervical dysplasia or neoplasia on an average of 5.7 years later, and the second presented following hysterectomy for benign or unrelated disease 13.1 years after initial surgery. All 17 patients in the first group had Stage I disease whereas two thirds of the second group had Stage II or greater disease at the time of diagnosis. Surgery was the primary mode of therapy in 82.4% of the first group and radiotherapy was used in 83.3% of the second group. In all patients 20.7% had received previous radiotherapy to the pelvis. Carcinoma of the vagina following hysterectomy for benign disease tends to be more advanced at the time of diagnosis and subsequently has a poorer ultimate prognosis. Disease following previous cervical neoplasia is often asymptomatic and only detected on routine cytologic testing.

Blunt abdominal trauma in pregnancy

Two cases are presented in which the effects of blunt trauma to a pregnant woman's abdomen were apparently minor but resulted in fetal death. Blunt trauma may result in serious injury to the fetus or the placenta. Three-point restraint systems should be worn by pregnant women travelling in automobiles to minimize the risks to mother and fetus. Awareness of the potential for injury in these circumstances is essential to reduce the risks to the fetus.