Biomedical subjects
Publications and source records attributed to R M Rome.
Vulvar sarcomas are uncommon, comprising only approximately 2% of all vulvar malignancies. Consequently, most reported series contain only a few cases. We add to the literature 10 cases of various primary sarcomas of the vulva, including previously unreported cases of angiosarcoma and a neoplasm resembling Ewing's sarcoma. The only histologic feature helpful in determining prognosis was tumor necrosis.
Thirty-five patients with advanced epithelial ovarian carcinoma (24 untreated, 11 previously treated with alkylating agents) were treated with a combination of cisplatin and etoposide (VP16-213). Tumor response (i.e., complete response and partial response) was seen in 16 of the 35 patients (i.e., 46%), with 5 complete responses. The response rate in previously untreated patients was 54%, but only 27% in previously treated patients. The median survival was 42 weeks. The toxicity of this regimen was severe. Twelve patients became severely myelosuppressed, including one septic death while severely neutropenic. Treatment with cisplatin and etoposide produces only average tumor response rates and patient survival, but is associated with severe toxicity. There is no evidence of synergy between cisplatin and VP16 in this study.
Estrogen and progesterone receptors have been measured in primary and secondary ovarian carcinoma in eight patients, in bilateral ovarian tumors in 16 patients, and from multiple sites within the same tumor in 16 patients (12 primary and 4 secondary). In the majority of cases, metastatic tumors contained less receptors than their primary tumors. Marked variations in receptor content were noted within the same tumor and between bilateral tumors. This variation in receptor levels may explain the discrepancy between the presence of receptors and the response to hormonal treatment. Multiple sites of ovarian carcinoma need to be assayed for receptor content before a final decision can be made on receptor status.
Second-look laparotomy has been performed on 76 patients with ovarian carcinoma each of whom was clinically free of tumour after completing a programme of postoperative chemotherapy (60 patients), pelvic radiotherapy followed by chemotherapy (14 patients) or observation (2 patients). The initial stage, bulk of residual tumour, completion of hysterectomy and bilateral salpingo-oophorectomy and an interval of 11 months or more between diagnosis and second-look surgery were all significantly (p less than .05) associated with negative findings. Recurrences occurred after a negative operation in 10 of 42 (23.8%) patients and were more frequent amongst patients with grade 3 tumours (p = .03). Macroscopic cancer was found in 23 (30.3%) patients and microscopic cancer in 11 (14.8%) patients. Survival was related to the surgical findings and to the amount of residual tumour at the conclusion of the second-look operation. Survival of patients with no macroscopic residue (those found to have microscopic tumour and those who had complete excision of macroscopic tumour) was significantly longer than that of patients with macroscopic residue (median survival 38.2 versus 19.0 months, p = .01). These results suggest that benefit from second-look laparotomy is confined to patients with microscopic or totally resectable tumour for whom second-line therapy may still be curative.
A series of 429 patients has been analysed in which the cytology smear report suggested human papillomavirus (HPV) infection alone. All patients were examined colposcopically and in 58 (13.6%) associated histologically confirmed cervical intraepithelial neoplasia (CIN) was demonstrated. CIN subsequently developed in an additional 10% of those patients who returned for follow-up over an ensuing 3-year period. Follow-up with repeat cervical cytology smears alone was unreliable as 4% of patients even with normal repeat smears has histologically proven CIN and a further 4% of these patients subsequently developed CIN. Colposcopy is recommended in all patients whose cytology smear shows HPV infection.
CA125 serum levels were assayed prior to 57 secondary laparotomies for ovarian epithelial tumours. Tumour was present in all 16 patients with an elevated level greater than 35 U/ml but the absence of tumour was incorrectly predicted in 15 of the 33 (45.5%) patients with CA125 levels less than 35 U/ml. For these patients the CA125 level was elevated in 14 of 20 (70%) with tumour greater than 1.5 cm, 1 of 7 (14.3%) with macroscopic tumour less than or equal to 1.5 cm and 1 of 4 (25%) with microscopic tumour. Tumour was resectable to less than or equal to 0.5 cm in 7 of 12 (58.3%) patients with CA125 less than 35 U/ml, 2 of 4 (50%) with CA125 in the range 35-100 U/ml and only 1 of 11 (9.1%) with CA125 greater than 100 U/ml (p less than .05). The CA125 level was elevated in 1 of 13 (7.7%) patients with less than 15 cm3 of tumour compared with 16 of 18 (88.9%) patients with 15 cm3 of tumour or more (p less than .0001). The correlation between the CA125 serum level and the tumour volume was almost statistically significant (r = +0.31, p = .053). The level of CA125 was normal in all 8 patients with mucinous tumours--4 of whom were found to have tumour at secondary surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
This study examines the natural history of human papilloma virus (HPV) atypia of the cervix in 259 untreated patients who were followed for 3 to 74 months (median 18 months). Progression to cervical intraepithelial neoplasia (CIN) occurred in 41 patients (15.8%)--all but 3 progressions occurred within the first 24 months of follow-up. In no patient did invasive cancer develop during this study. Persistence occurred in 39.4% and regression in 44.8% patients. An increasing number of regressions were noted with the passage of time. Progression to histologically confirmed CIN which occurred in 23 of 46 (50%) patients in whom both the cytological and colposcopic assessment at the first visit suggested CIN did so significantly more frequently than when either the cytology or colposcopy alone suggested CIN (11 progressions in 83 patients--13.3%, p less than .00001) or when neither cytology nor colposcopy suggested CIN (7 progressions in 119 patients--5.9%, p less than .000001). We recommend that patients with both cytological and colposcopic features suggestive of CIN should be treated even though HPV atypia only is reported on biopsy. Those who are not treated should be followed closely until regression occurs and consideration should be given to treating those patients in whom the abnormality persists longer than 2 years.
This study analyzes the clinical and pathological features of 76 patients who were diagnosed as having ovarian low malignant potential tumor over a 20-year period: 39 (51.3%) of the tumors were mucinous, 29 (38.2%) serous, three (3.9%) endometrioid, and five (6.6%) mixed. Patients with serous tumors were significantly younger (mean age 40 years) than those with mucinous tumors (mean age 50.5 years). Serous tumors were more frequently bilateral (48.3%) than mucinous tumors (12.8%). The extent of tumor (FIGO stage) at the primary laparotomy was related to the prognosis: the survival of 14 patients with stage III and six patients with stage II tumor was significantly inferior to that of the 56 patients with stage I tumors (P less than .01). Patients with stage III mucinous low malignant potential tumors and pseudomyxoma peritoneii fared badly. Four patients with stage II and 13 patients with stage III tumors had residual tumor after primary surgery. Five of these patients received no subsequent treatment of whom four are alive and well from 5.5 to 19 years after diagnosis. Three patients received pelvic radiotherapy. Eleven patients were treated with chemotherapy for residual or recurrent tumor but only one (9.1%) had an unequivocal response.
This paper outlines the pitfalls encountered in the diagnosis of 127 preclinical cancers of the cervix. Each patient had cervical cytology, colposcopy, and histology performed within the same institution. Early stromal invasion was diagnosed in 55 patients and occult invasion was diagnosed in 72 patients. For preclinical cancers as a group, the possibility of invasive carcinoma was predicted cytologically in 36% and suspected colposcopically in 41%. However, in over 85% of patients the abnormal transformation zone (TZ) extended into or was totally confined within the endocervical canal and could not be adequately evaluated with the colposcope. A feature of this study was the high incidence of incomplete excision of abnormal tissue by cone biopsy and a high incidence of residual disease at hysterectomy. Cone biopsy was necessary to accurately assess the maximum depth and extent of invasion prior to definitive therapy whenever invasion was suspected colposcopically or on target biopsy. In 10 of 16 such patients, the cone biopsy demonstrated occult invasion. Colposcopy and directed target biopsy alone was adequate for the diagnosis of frank invasive cancer in 22 of the 72 patients in the occult invasion group, enabling definitive therapy to be undertaken without further delay.
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This paper deals with diagnosis, detection and treatment of early female genital tract malignancy and its precursors. In general the precursors are eradicated easily and with preservation of childbearing function; the earlier stages of malignancy often can be treated with low morbidity and a high probability of cure.
The present report assesses 15 years' experience with electrocoagulation diathermy in the treatment of cervical intraepithelial neoplasia (CIN). Selection is based on the ability to visualize the boundaries of the lesion colposcopically. Visualization, together with cytology and target biopsy, should exclude invasive carcinoma. Histologically confirmed CIN of varying severity (almost two thirds were CIN III) was treated by diathermy in 1864 patients. The size of the lesion varied, and at times the lesion extended into the endocervical canal. Cervical intraepithelial neoplasia was eradicated in 97.3% of patients by a single diathermy treatment. Ninety-three percent of all patients under the age of 30 with CIN were treated by this method. Progression to invasive carcinoma after diathermy has not been demonstrated. A single treatment with electrocoagulation diathermy has proved consistently to be the most effective superficial ablative method for primary eradication of CIN whether deep, extensive, or of major severity.
Estrogen excretion was higher than normal (more than 9 microgram/24 hr) in 40 of 80 postmenopausal women with benign and malignant epithelial tumors of the ovary, including 8 metastatic tumors. High estrogen excretion was noted in 19 of 27 (70.4%) patients with mucinous tumors in only 1 of 25 (4%) patients with serous tumors (P less than .001). Endometrioid and metastatic tumors were also noted to be frequently associated with high estrogen excretion. In the high estrogen excretion group 27 of 37 (73%) patients showed stromal luteinization and/or condensation in the tumor, but in the normal estrogen excretion group these changes were seen in only 6 of 38 (15.8%) patients (P less than .001). A possible mechanism of stromal stimulation in these tumors is discussed. Although there was often evidence of estrogen activity in the endometrium and the tubal epithelium in the high estrogen excretion group, the correlation between these epithelia and estrogen excretion was imperfect. Postoperative estrogen excretion remained elevated in 3 of 16 patients, of whom 1 was obese and 2 had residual tumor. This study emphasizes the importance of identifying epithelial tumors of the ovary as functioning or endocrine tumors.
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Numerous tests have been proposed in recent years to screen the antenatal population for various diseases which might contribute to perinatal and even maternal morbidity and mortality. Screening tests of any kind are currently the centre of controversy as measures are being strenuously taken to contain health costs. This paper critically examines twelve such screening tests.
The apparent area of the abnormal transformation zone (TZ) of the cervix was measured in a total of 104 patients by a simple method with the use of the 1 and 5 mm. diameter circle in the center of the field of the Leisegang colposcope and the field of the colposcope itself. The visible area (mean +/- S.E.M.) of the abnormal TZ for five patients with microinvasive or occult carcinoma of the cervix (180.8 mm.2 +/- 62.2) was significantly larger (p less than 0.01) than that of 64 patients with major intraepithelial lesions (62.5 sq. mm.2 +/- 7.3) and 35 patients with minor intraepithelial lesions (45.8 sq. mm.2 +/- 11.7). The visible area of the abnormal TZ measured over 40 mm.2 in each of the five patients with invasive lesions but in only 42 of 99 (42%) patients with intraepithelial lesions. The TZ extended into the endocervical canal and could not be fully visualized in four (80%) of the patients with invasive lesions, 24 (38%) of patients with major intraepithelial lesions, and 11 (31%) of patients with minor intraepithelial lesions. The implications of these findings are discussed.
A total of 259 patients underwent endocervical curettage as an integral part of colposcopic examination of patients with abnormal cervical cytology. The transformation zone was entirely visualized in 140 patients (54.1 per cent), and, in 8.6 per cent of this group, the endocervical curettings were abnormal. On no occasion did the endocervical curettage harbor the worst lesion when compared to the histology of the ectocervical biopsy, cone biopsy, and hysterectomy specimens. In 117 patients (45.2 per cent), the transformation zone could not be visualized in its entirety, and in 57.3 per cent the endocervical curettings were abnormal. In one patient of this group invasive carcinoma was present in the endocervical curettage, and in another patient invasive carcinoma was present in both the ectocervical biopsy and the endocervical curettage. Thus, when the entire transformation zone is not visualized in its entirety or at all, endocervical curettage appears to be of value since a frank invasive carcinoma may be diagnosed and a cone biopsy avoided.
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