Prevention of exposure to bloodborne pathogens

Vaginal cancer, 2% of all female genital malignancies, has a worse prognosis than cervical cancer. Squamos cell carcinoma, the most common histologic subtype, may be associated partly with human papillomavirus. Most patients present with vaginal bleeding and discharge. Radiation or surgery are the main treatment modalities, but the physical and psychosexual morbidity can be significant.     

Colon adenocarcinoma and B-16 melanoma grow larger following laparotomy vs. pneumoperitoneum in a murine model

BACKGROUND: The purpose of our study was to find out whether bleeding symptoms are predictive factors of subsequent gynecological or urinary cancers among women screened negative. METHODS: The data stemmed from the Finnish Mass Screening Registry, and were linked to the National Cancer Registry: 37,596 screening negative women in the nationwide population-based mass screening program for cervical cancer were classified by their bleeding symptom (bloody discharge, coital bleeding, irregular bleeding, postmenopausal bleeding) at the time of screening (1985-1990) and followed up (1985-1994) in order to assess the subsequent risk of cancer. RESULTS: Bleeding symptoms with prevalence of 5.9% were more likely to be signs of preinvasive than invasive cervical cancer with the exception of coital bleeding, nevertheless relative risk of cervical cancer (SIR 1.1, 95% CI 0.8-1.4) was not significantly increased during the total follow-up of maximum 10 years. Women with any bleeding symptom had increased risk of cancer of the corpus uteri (SIR 2.1, 95% CI 1.6-2.6), postmenopausal bleeding was the strongest symptom (RR 3.6, 95% CI 2.0-6.0). None of the bleeding symptoms increased subsequent risk of ovarian, vaginal or vulvar carcinoma. The risk of kidney cancer was increased (SIR 1.7, 95% CI 1.0-2.6). CONCLUSIONS: The prevalence of bleeding symptoms was small and relative risks for cancers were low for them to be suitable as predictive factors of cancer neither in clinical practice nor for public health purposes, e.g. in developing selective screening based on this high risk group. Only 34 gynecological cancers during 220,000 person-years in women with bleeding symptoms were attributable to bleeding. Relative risks remained increased only for a short time after screening. Therefore, short term surveillance is important, but due to the fact that relative risks approached unity during the follow-up, reassurance of a woman that she is cancer-free should be emphasized more in the long term after the bleeding symptoms.     

Clinicoepidemiologic study of uterine cancer. Comparative aspects of the endometrial and cervical sites

A review of all newly diagnosed cases of cervical and endometrial carcinoma in Israel during the 5-year period of 1961-1965 yielded mean annual incidence rates of 4.9/100,000 and 7.4/100,000, respectively. Cervical cancer was more prevalent in Moroccan-born women and among divorcees, while the risk of endometrial cancer was highest in older age, among the European born, and the single; it also appeared earlier in life. Postmenopausal bleeding constituted the most frequent first symptom in both sites. Fifty percent of the patients of both groups were diagnosed within 1 month, but the delay was somewhat longer in the endometrial group. Median survival was 5 years in patients with cervical cancer and above 12 years in those with cancer of the corpus. Five-year survival was 50 and 75%, respectively. Survival tended to be better in younger patients in both groups. It is expected that the gradual disappearance of intraethnic differences in Israel would lead to a decrease in the incidence of invasive cervical cancer, coupled with an increased incidence of the endometrial category.     

Influence of delayed diagnosis on established prognostic factors in endometrial cancer

To evaluate the influence of delayed diagnosis on prognostic factors in endometrial cancer, we conducted a retrospective chart analysis based on the data of 116 postmenopausal patients with FIGO stage I-IV endometrial carcinoma. The interval from the first episode of post-menopausal vaginal bleeding to definitive, histological diagnosis (bleeding interval) was compared with tumor stage and various histomorphologic features in endometrial cancer. The mean bleeding interval was 12.7 +/- 17.8 weeks in 74 patients with FIGO stage IA, IB endometrial carcinoma and 35.2 +/- 69.3 weeks in 42 patients with stage IC-IV disease (t-test, p: 0.011). FIGO stage IA, IB disease was diagnosed in 23/26 (88%) patients with a bleeding interval <4 weeks, and in 22/34 (64%) and 29/56 (51%) patients with bleeding intervals of 4-8 weeks and >8 weeks, respectively (Chi-square 10.358, p=0.006). The correlation with histologic grade, lymph-node status, vessel invasion and histologic subtypes did not reach statistical significance. Our data confirm the clinical impression that postmenopausal vaginal bleeding is an early symptom in patients with endometrial cancer, and that advanced disease in the majority of cases might come from delayed diagnosis in women with poor compliance.     

Reappraisal of Ikeda''s classification of alopecia areata: analysis of 356 cases from Chandigarh, India

Human papilloma virus (HPV; 16 and 18) is known to play an important etiologic role in cervical dysplasia, but its relationship with anal carcinoma is still unclear. Surgical samples from 80 female patients treated for anal epidermoid carcinoma in the Polyclinic of Surgery in Geneva between 1976 and 1989 were retrospectively studied. Of these, HPV detection was performed in 41 whose DNA was preserved well enough to allow such an analysis. Seventeen (42%) samples contained HPV, with a high percentage of high risk HPV (15/41, 36%). Thirty-eight of the 80 patients had a cervical smear, of which 18% revealed cervical carcinoma. When compared with epidemiological data, the results of this study suggest that genital HPV infection predisposes not only to cervical cancer, but also to anal carcinoma, possibly by means of contiguous contamination.     

Management of cervical neoplasia in human immunodeficiency virus-infected women

The existence of cervical neoplasia in women with human immunodeficiency virus (HIV) represents one of the most serious challenges in the oncologic care of immunosuppressed patients. While the development of most cancers in the immunosuppressed patient can be attributed solely to immune deficiency, the relationship between squamous cell neoplasia of the cervix and HIV is quite unique because of common sexual behavioral risk factors. Screening strategies in HIV-positive women must take into account the high prevalence of cervical dysplasia in this subgroup as well as the limitations of cytologic screening. Cervical dysplasia in HIV-positive women may be of higher grade than in HIV-negative patients, with more extensive involvement of the lower genital tract with HPV-associated lesions. The presence and severity of cervical neoplasia in HIV-positive women correlate with both quantitative and qualitative T-cell function. Standard therapies for preinvasive cervical disease have yielded suboptimal results with high recurrent rates. While poor treatment results of standard ablative and excisional therapies warrant unique therapeutic strategies, one must recognize that close surveillance and repetitive treatment have been successful in preventing progressive neoplasia and invasive cervical carcinoma. The disease characteristics of invasive cervical carcinoma may take a more aggressive clinical course in HIV-infected women. HIV-positive women with cervical cancer have higher recurrence and death rates with shorter intervals to recurrence and death than do HIV-negative control subjects. CD4 status does influence subsequent outcome. In general, the same principles that guide the oncologic management of cervical cancer in immunocompetent patients should be applied. However, extremely close monitoring for both therapeutic efficacy and unusual toxicity must be instituted.     

Children with chronic arthritis: the management of transition to adulthood

Primary fallopian tube carcinoma represents less than 1% of all gynecologic malignancies and is therefore one of the less common malignancies of the female genital tract. Fallopian tube carcinoma is rarely diagnosed preoperatively and is often mistaken for benign pelvic disease or ovarian cancer. Compared with ovarian carcinoma, fallopian tube cancer more often presents in early stage but seems to have a worse prognosis, stage for stage. Treatment consists of surgical debulking followed by chemotherapy, adjuvant or otherwise. New studies are needed to better delineate the clinical course, prognostic factors, and appropriate chemotherapy recommendations.     

Subacute orbital abscess in a four-year-old girl with a new kitten

BACKGROUND: Carcinoid tumors are neoplasms of neuroendocrine origin that rarely affect the genital tract. CASE: A 75-year-old woman underwent hysterectomy and bilateral adnexectomy due to vaginal bleeding and uterine pathology (leiomyoma, cervical low grade squamous intraepithelial lesions and endometrial hyperplasia on ultrasound). Pathologic examination of the specimen disclosed a uterine corpus carcinoid tumor. The patient had been taking tamoxifen for adjuvant treatment of breast cancer diagnosed and treated seven years before. CONCLUSION: A review of the literature revealed one case of carcinoid tumor of the uterine wall. There does not appear to be any relationship between tamoxifen and the carcinoid tumors reported.     

Detection of human papillomaviruses (HPV-16,18) in cervical smears by in situ hybridization

The rate of human papillomaviruses (HPV) 16 and 18 infections were measured in 109 women with histologically or cytologically determined lesions of the uterine cervix and in 42 healthy women. Cervical swabs were taken as the source of the target viral DNA. In situ hybridization with biotinylated probes was used. HPV-16 was the predominant type in patients and in healthy women. The percentage of positive cases was the highest in cervical cancer patients: 43.3% in squamous cell carcinoma and 33.3% in adenocarcinoma followed by cervical intraepithelial neoplasia (CIN), III, II (21.4%), CIN I (14.3%) and low grade squamous intraepithelial lesions (13.6%). HPV-18 type was detected in a lower percentage in the three groups of patients. In healthy women HPV-16 was determined in 12% and HPV-18 in 4.8%. We believe that the described noninvasive method of obtaining clinical material should be the method of choice for estimating papillomavirus infections in patients and in the general population. Our results are in agreement with suggestions that HPV genotype could be an important prognostic indicator in cervical carcinoma.     

Studies on the immune status of patients with operated and irradiated cervical and breast cancer. III. Comparative investigation of the immune status of patients with breast cancer treated by operation and irradiation and of patients with cervical cancer treated either by operation or irradiation (author's transl)

The immunological reactivity of 19 operated cases of breast cancer (14 T1 2, 5T3) was investigated before and at 3-weekly intervals up to 12 weeks after radiotherapy by means of a large panel of techniques. The results were compared with two groups of identically-investigated patients, one consisting of 11 cases of cervical cancer (stage III), treated solely by irradiation and the other of 12 cases of cervical cancer (Stages I a and II b), treated by operation only. Before irradiation and in the non-irradiated group cellular immunity appeared to be more disturbed in cases of breast cancer than in cases of cervical carcinoma, as shown by the lowest number of lymphocytes, the lowest number of spontaneously-rosetting lymphocytes, the lowest percentage of DNCB sensitization in patients and the lowest percentage of Tuberculin-positive skin tests. In both types of carcinoma the humoral immunity appeared to be impaired, as apparent from the lowered immune response to tetanus vaccination. Other parameters of humoral immunity such as the immune globulin concentration, iso- and heteroagglutinine, the titre of measles antibodies or membrane fluorescence of lymphocytes showed no dinstinct trends during the investigation period. After irradiation a) inhibiting and b) stimulating influences were observed: a) The incidence and extent of the immune response to tetanus vaccination was further reduced and a distinct lymphopenic effect was observed. b) The incidence of positive skin tests with varidase, as well as the number of spontaneously-rosetting lymphocytes increased after the commencement of irradiation. Apart from the known sensitization with DNCB and skin tests with tuberculin, determination of the antitoxin titre before and after tetanus vaccination provided the most reliable results in regard to immunological reactivity in the investigated tumour patients.     

Hemorrhages in abnormal production of gonadotropins

A review of the organic and hormonal causes of irregular menstrual bleeding is presented. Menstrual bleeding irregularities are the most frequent gynecological ailment. Oligomenorrhea is most often caused by a prolonged proliferation phase in the menstrual cycle. In younger women this may be due to insufficient hormonal secretion of the pituitary gland; in older women it may be due to late follicular development in spite of normal glandular secretion. Polymenorrhea is usually caused in younger women by a shortening of the proliferation phase, usually because the ovaries are hypersensitive to pituitary hormones, which causes an aceleration of follicular development. Polymenorrhea in older women is usually due to a shortened secretory phase caused by early degeneration of the corpus luteum, and later may develop into oligomenorrhea or amenorrhea. Irregular corpus luteum function after ovulation can cause bleeding irregularities. When the corpus luteum fails to produce progesterone, the endometrium develops irregularly, causing premenstural spotting or increased volume of menstrual bleeding. Slow degeneration of the corpus luteum causes increased progesterone production and irregular discharge of the endometrium. Anovulation is the most frequent cause of bleeding irregularities, because there is no progesterone secretion. A quick increase in estrogen production in the proliferation phase in conjunction with anovulation causes an irregular discharging of the endometrium with prolonged or increased bleeding. A slow increase in estrogen production during the proliferation phase in conjunction with anovulation causes hyperplasia. In a few patients, anovulation in conjunction with a secretion of estrogen insufficient to maintain the endometrium can cause endometrial atrophy. Irregular bleeding is usually functional in younger women and organic in older women. To diagnose the cause of irregular menstrual bleeding, organic reasons should be explored 1st. A complete history should be taken, then abrasio, recording the basal temperature, and hematological, and hormonal analysis should be used to pinpoint the causes of irregular bleeding. Abrasio is the most common treatment for bleeding irregularities, and hormone treatment is the 2nd most common. Hysterectomy should be used only in extreme cases for treatment of bleeding irregularities.     

"HPV effect" in the female lower genital tract. A community study

OBJECTIVE: To determine the distribution of "human papillomavirus (HPV) effect" and intraepithelial neoplasia in the lower female genital tract in one community with a prospective study. STUDY DESIGN: In a family practice setting, colposcopy was offered to all women presenting for a routine cervical cytologic smear. Directed biopsies were taken from areas staining abnormally with acetic acid or iodine. RESULTS: This study of 224 women showed a high incidence of HPV effect in the lower genital tract (68%), including 18% on the vulva. The age distribution suggests a coital influence. A five-year review showed persistence of HPV effect on the vulva or vagina in only one patient. One other woman developed cervical intraepithelial neoplasia (CIN) 1. CONCLUSION: HPV effect is common in the lower genital tract of women under the age of 30 years. Colposcopic study suggested that HPV effect on the vulva and vagina is transient. The relatively high incidence of HPV effect on the vulva may explain why cervical HPV and CIN generally appear only after coitarche, as a consequence of physical transfer. This may help explain why women with a single lifetime sexual partner are not exempt from the risk of cervical cancer or its precursors.     

Immunotherapy for non-Hodgkin''s lymphoma

The genital human papillomavirus (HPV) is directly associated with cervical cancer, the second most common form of cancer among women. The study was guided by a synergistic interaction model of HPV risk factors. The relative risk of selected risk factors and cofactors associated with genital HPV infections was identified. Women at highest risk for acquiring an HPV infection had (a) initiated sex before age 15, (b) more than four lifetime sex partners, (c) more than one "once only" sexual partner, and (d) chosen male sex partners who previously had > 16 other female sex partners. Cofactors that increased risk by possibly contributing to progression of genital HPV infection were initiating oral contraceptive use before age 15 and having acquired more than three other sexually transmitted diseases. Past and current smokers were at a slightly higher risk compared to nonsmokers. Although other studies have identified risk factors, few have identified the relative risk of these factors.     

Tracheal intubation in infants

BACKGROUND: So far only a few cases of carcinoma in situ of the fallopian tube have been reported, but its detailed clinical and pathologic findings, including cytology, have not been fully described. CASE: A 70-year-old female was admitted to our hospital because of irregular genital bleeding. Endometrial smear revealed a small number of atypical cells with a clear background. Hysterectomy, bilateral salpingo-oophorectomy and omentectomy were performed. Grossly, a grayish white papillary tumor, measuring 1.5 x 1.0 cm, was observed within the lumen of the left fallopian tube. Microscopically, the diagnosis of papillary adenocarcinoma in situ of the left fallopian tube was made according to 1992 International Federation of Gynecologists and Obstetricians fallopian tube staging. CONCLUSION: Although endometrial brush cytology is not sensitive enough to detect a primary carcinoma of the fallopian tube, our case indicates that it may contribute useful information on extrauterine diseases and can detect a stage 0 cancer of the fallopian tube. Clinicians, as well as pathologists, should consider the possibility of fallopian tube cancer if cervical or endometrial cytology shows atypical cells with papillary patterns with a clear background but endometrial curettage cannot prove malignancy.     

Method for objective assessment of physical work load at the workplace

In Miyagi Prefecture, mass screening for cervical cancer was initiated in 1961. We organized the project in cooperation with the Miyagi Cancer Society. Because cases detected in mass screening were treated earlier, their prognoses were better than cases diagnosed in outpatient clinics. A high proportion of patients detected in stage 0 and I showed improved prognoses. In 1983, the central government established the first Health and Medical Services Law for the Aged to support the project. The standardized death rate of cervical cancer in Miyagi Prefecture fell from 12.1 per 100,000 in 1961 to 4.0 per 100,000 in 1994. A case-control study revealed that women who were screened, compared with women who had no prior screening, had an odds ratio for invasive cervical cancer of 0.14. The time interval of following the last negative smear was assessed, and we found that an odds ratio for a one-year interval was 0.09. However, there still remain problems, such as the lack of a further increase in the screening rate, fixation of examinees, and increase in the incidence of young women. Uterine body cancer is one of the increasing malignancies in Japan, as well as worldwide. Its epidemiological characteristics are as follows; 1) over 50 years old, 2) infertile and irregular menstruation, 3) post-menopause, and 4) atypical genital bleeding. Screening for uterine body cancer was started in 1987 under the second Health and Medical Services Law for the Aged. The target of the screening is limited to cases with the high-risk factors above described. We reported the results of mass screening in Miyagi Prefecture, elucidated the characteristics of uterine cancer detected by mass screening, and indicated the problems.     

Campaign for cervical cancer screening with vaginal smears in women aged 50-69 years in Isère (France). Results of the first round (January 1991-June 1993)

The department of Isère, which is involved since 1990 in a breast cancer screening campaign concerning women aged 50 to 69, has managed to associate a cervical and colorectal cancers screening program. The target sample size is 98,000 individuals. Women are asked to refer their general practitioner or gynaecologist for cervicovaginal smears. Each woman is invited at a screening interval of 30 months. The results of the first invitation (November 1990-December 1992) are reported. Thus 29,570 women did referred, so that the screening uptake is 30% and 20,083 women (68%) had Pap smears inside the screening program. 1.1% of the smears were unsatisfactory and 1.2% of the tests showed abnormalities. Ninety-six percent of the women who had been referred for further examinations have been followed up. Thirty-eight women (representing 17% of smears with abnormalities) had surgery (conisation, hysterectomy, Wertheim). Among them, 5 cases of invasive cervical carcinoma and 25 in situ carcinoma were detected. The detected cancer prevalence per 1,000 women screened is 1.5/1000. An organised screening program for cervical cancer in association with breast cancer screening, seems to be an effective way of increasing smears realisation in women aged 50 to 69, and of involving general practitioners in cervical cancer screening.     

Establishment of transgenic mice carrying human fetus-specific CYP3A7

OBJECTIVE: To determine the value of cytology in the follow-up of cervical cancer. STUDY DESIGN: The study group consisted of 230 patients with invasive cervical carcinoma who were followed for one to seven years. Forty-four patients developed recurrences or metastases. During this period, cytologic investigations involved 795 exfoliative smears from the cervix or vaginal vault, 10 fine needle aspirates and 5 fluids. RESULTS: Thirty-three patients had positive or inconclusive cervical or vault smears that were histologically proven to be recurrences, and the other 11 patients had clinically obvious recurrences that were not smeared. Cytology first alerted the clinicians to recurrence in eight patients. Of 25 cervical or vault smears reported as malignant, 24 (96%) were histologically confirmed, and 1 showed radiation change on biopsy. In all 22 cases of smears reported as inconclusive, a biopsy followed, and in 9 (41%) of these, recurrence was demonstrated histologically. Inability to distinguish radiation change from recurrent malignancy was the chief cause of inconclusive smears. Five fluids and seven fine needle aspirates were diagnosed as malignant, saving patients an invasive diagnostic procedure. CONCLUSION: Cytology is a useful, cost-effective, noninvasive and accurate investigation in the follow-up of cervical cancer.     

Screening for cervix carcinoma--a retrospective comparison between new and established federal German states

OBJECTIVE: There is no doubt about the effect of cytological screening programmes on the reduction of incident cases with invasive cervical carcinoma. The question is, to what extent this reduction was caused by cytological screening exclusively. A retrospective analysis of the former East German cytological mass screening could give information of early and late screening effects and also on the efficacy. Based on data from the Saarland cancer registry, common aspects and differences between the old and new federal states of Germany can be addressed regarding incidences and mortality trends for cervical carcinoma. RESULTS: Since the sixties the incidence of CIS has increased by 625% while the incidence of invasive carcinoma has decreased by 44% in the new federal states. Since the seventies mortality due to cervical carcinoma decreased by 44%. Incidences and mortality rates of the Saarland were considerably lower than of the new federal states. CONCLUSION: This study describes noteworthy early screening effects and proves the efficacy of mass cancer screening. Changes of incidence and, particularly, mortality rates are not exclusively due to these programmes.     

Hemodynamic effects of intrathecal fentanyl in nonlaboring term parturients

220 cases of gastric cancer were selected from Dakar Hospitals during seven years (1984-1991). This retrospective study confirms that gastric cancer is the most common cancer of the Gastro-intestinal tract (48.4%). The sex ratio was 2.7 (M/F) with mean age of 50 years. However, a steady progression of gastric cancer was noticed beginning at 40 years. Despite the introduction of upper gastro-intestinal endoscopy the classical evolved form was the most commonly found (83.2%). The associated lesions known to be premalignant were found in 22.7% of cases. The patients were seen with a long delay after the first symptoms. This is why we have long delays of diagnosis in our centers. 61.7% of them are seen 3 to 12 months after their first symptoms. In 70% of cases, lesions were found on antropyloric region. The most common histological type remain adenocarcinoma (90% of cases). Even though endoscopy has contributed to increase the incidence of gastric cancer, it did not allow to discover early gastric carcinoma.