Diagnostic cytology for detection of early cancer

Cytologic methods for detection of early cancers of the uterine cervix, lung and various other organs are discussed. The scraping smear method using a spatula is more effective than the cotton swab or vaginal pool smear method for detection of preinvasive intraepithelial lesions, such as, carcinoma in situ and dysplasias of various degrees of the uterine cervix. The use of sputum specimens pooled for three to five days is recommended for cytologic examination in population screening of lung cancer. Good cytopreparatory techniques, suitable screening and cytodiagnostic classifications of malignancy are also described and emphasized, especially, the importance of properly fixed cytologic material for correct cytopathological diagnosis.     

A pilot study on concurrent platinum chemotherapy and intracavitary brachytherapy for locally advanced cancer of the uterine cervix

This study aims to evaluate the feasibility, toxicity and efficacy of concurrent chemotherapy with platinum compounds and brachytherapy, for locally advanced carcinoma of the cervix (Stages IIA/B, IIIA). The hypothesis was that synchronous chemo-brachytherapy may be sufficient to cause down-staging of the tumour, to render it operable, and hopefully improve the prognosis. 36 women with locally advanced cervical cancer were treated with concomitant brachytherapy and chemotherapy before surgery and/or definitive external radiotherapy. All patients received two caesium-137 Selectron MDR applications, 1 week apart. The dose calculated to point A for each implant was 20-25 Gy. Chemotherapy consisting of continuous cisplatin infusion (50 mg m2) and of carboplatin (300 mg m-2) was given simultaneously with intracavitary irradiation during the first and second application, respectively. The combined therapy was followed when feasible by radical hysterectomy, pelvic lymphadenectomy and pelvic radiotherapy. Patients deemed ineligible for surgery because of poor response were given full dose external radiotherapy. 31/36 patients were treated by Wertheim hysterectomy of whom 10 had negative lymph nodes and resection margins. Definitive external radiotherapy was given in the remaining five patients. Overall, 83% were disease free at 2.8 years mean follow-up. The most frequent acute side-effects of chemobrachytherapy were nausea and vomiting. No renal toxicity was observed. Thrombocytopenia was seen in five patients and was responsible for delayed surgery in four patients. Concerning late effects, two patients developed grade 2 intestinal sequelae, two mild frequency and two vaginal stenosis. One rectovaginal and one vesicovaginal fistula developed in two patients; and a third patient had a fistula associated with tumour recurrence. Concurrent brachytherapy and chemotherapy with platinum compounds is well tolerated and effective in reducing tumour bulk before definitive local treatment (surgery or external radiotherapy), in patients with locally advanced carcinoma of the uterine cervix.     

Specific respiratory manifestations associated with hemorrhagic rectocolitis. Analysis of a case and review of the literature

In a 59-year-old woman suffering from the syndrome of inappropriate antidiuretic hormone secretion, a small cell carcinoma of the uterine cervix was detected. The tumor was immunoreactive for antidiuretic hormone as well as for neuron specific enolase, chromogranin A, and Leu-7, but not vimentin. Electron microscopic examination of the tumor revealed neurosecretory granules. To our knowledge, this is only the second report of the syndrome of inappropriate antidiuretic hormone secretion with small cell carcinoma of the uterine cervix and the first one confirmed immunohistopathologically.     

Mucosal de novo cancer of the rectum following radiation therapy for uterine cancer

A 54-year-old woman who underwent a hysterectomy and radiation therapy for carcinoma of the uterine cervix developed mucosal de novo cancer of the rectum 12 years later. The rectal lesion was elevated, measuring 0.8 x 0.7 x 0.3 cm, and its surface was relatively smooth. Microscopically, this tumor consisted of a well-differentiated tubular adenocarcinoma which had invaded the depth of the mucosa. Late radiation injuries were observed around the tumor. We diagnosed this lesion as a radiation-induced mucosal de novo adenocarcinoma of the rectum on the basis of the criteria of Black and Ackerman (Clin Radiol 16:278, 1965). This case underscores the need for careful long-term follow-up studies of the large intestines of patients who underwent therapeutic irradiation for uterine cancer.     

The vaginal transverse low segment hysterotomy for second trimester therapeutic abortion (author's transl)

A series of 100 therapeutic abortions by vaginal hysterotomy is reported. This method of vaginal hysterotomy with a transverse low segment incision just above the internal os of the cervix was first described by Fuchs in 1939. The important advantage of this method is complete avoidance of the uterine cervix. With this method a therapeutic abortion after the tenth week of gestation and in a few cases, up to the 20th week of gestation can be accomplished by a fast one stage technique with few side effects. The method is considered to be superior to the injection methods and the two stage procedures. With skill in vaginal operative techniques, this method can be used in any gynaecological department as a routine method. In this series, 28 cases had concomitant tubal ligations. There were two subsequent pregnancies. Complications were one uterine perforation during the curettage requiring laparotomy and suture. There was one laceration of the trigon of the bladder requiring suture. There were 2 cases of hemorrhage. There were 6 inflammatory reactions in the perimetria of which two required administration of antibiotics. There was superficial thrombophlebitis in one case. And there was a severe coagulation defect in one case of a missed abortion at 5 months gestation.     

Abdominal radical trachelectomy: a new surgical technique for the conservative management of cervical carcinoma

Traditionally radical hysterectomy has formed the mainstay of treatment for early stage cervical carcinoma. More recently radical trachelectomy and laparoscopic lymphadenectomy have been introduced to allow preservation of fertility. We present a new approach to fertility-sparing surgery, namely abdominal radical trachelectomy. The technique is similar to a standard radical hysterectomy and lymphadenectomy. In our technique the ovarian vessels are not ligated and, following lymphadenectomy and skeletonisation of the uterine arteries, the cervix, parametrium and vaginal cuff are excised. The residuum of the cervix is then sutured to the vagina and the uterine ateries re-anastomosed.     

Classification of qh regions in human chromosomes 1, 9, and 16 by C-banding

The occurrance of polyps of the uterine cervix during childhood is described which is exceedingly rare according to the literature. A pediatric gynaecological outpatient department was established two years ago and among about 600 children examined by viginoscopy, nine children with polyps of the cervix were detected. All nine girls had similar symptoms and signs. There was vaginal bleeding with malodorous discharge which could also be characteristic of a malignant tumor. The vaginal introitus was rather larger with an almost absent hymen. It is important to recognize the conditions early and to treat it. The vaginal discharge was treated. The polyp was removed and the base of the polyp was coagulated to avoid a recurrence. It can be expected that polyps of the uterine cervix in childhood will be found more often as the interest in pediatric gynaecology increases.     

Comparative study of AgNOR and PCNA in experimental carcinogenesis of salivary glands of rats

The findings of MRI and pathologic investigation were correlated in curatively irradiated uterine cervical carcinoma. Four patients having residual carcinoma diagnosed by biopsy underwent hysterectomy. MRI demonstrated the mass lesion in one patient with pathologic confirmation of massive viable cancer cells (case I). Of the other three patients, MRI demonstrated normal configuration of the uterine cervix. Cervical signal intensity, however, varied. Hyperintensity was noted in an area of the posterior wall on T2WI in case 2. The anterior wall of the case 2 and the other two cases showed hypointensity. Cervical specimens with normal intensity showed only a small number of degenerated cancer cells. On the other hand, pathologic examination of the posterior wall of the case 2 revealed both cancer cells with varying degrees of degeneration and necrotic tissues. Degeneration of cancer cells was stronger in the superficial layer than the deeper layer. Fibrosis, hemorrhage, granulation and hyalinization were hypointense on T2WI. T2 elongation reflected not only the residual tumor but the post-irradiation changes. Post-irradiated cervix with normal intensity indicated that only a small number of degenerated cancer cells may persist even if the biopsy was positive. We conclude that MRI is useful in evaluating tumor response to radiotherapy.     

Intrauterine high dose rate afterloading brachytherapy: experience of fractionated therapy using a cervical sleeve technique

Using a standard three-channel Manchester-type tube and ovoid high dose rate applicator system, 46 consecutive patients have been treated for carcinoma of the cervix or endometrium. To facilitate fractionated treatments using high dose rate afterloading, a technique has been developed using an indwelling cervical sleeve inserted under an initial general anaesthetic. All patients received at least two insertions; in five patients we have delivered a total of six consecutive fractions on an outpatient basis without anaesthesia once the sleeve was in situ. Acute morbidity related to the procedure was some degree of uterine pain, which was relieved with nitrous oxide inhalation, and mild, but self-limiting, vaginal discharge. Complete late morbidity data are not yet available, but, in 30% of 25 evaluable patients, minor problems have been observed, particularly vaginal oedema and stenosis. Only one major late event has required surgery. Fractionated afterloading intrauterine brachytherapy can be delivered on an outpatient basis without anaesthesia using this cervical sleeve technique.     

Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse

OBJECTIVE: The purpose of this study was to determine the simplicity, safety, anatomic, and functional success of using the uterosacral ligaments for correction of significant complex uterine and vaginal vault prolapse by the vaginal route. STUDY DESIGN: Fifty women with uterine or vaginal vault prolapse with descent of the cervix or the vaginal vault to the introitus or greater were treated between 1993 and 1996 by the same surgeon with bilateral uterosacral ligament fixation to the vaginal cuff by the vaginal route. Included were patients with significant enterocele, cystourethrocele, rectocele, and stress urinary incontinence who had concomitant repair of coexisting pelvic support defects. An etiology of vaginal vault prolapse is discussed. RESULTS: Uterosacral ligaments were identified and used for successful vaginal vault suspension by the vaginal route in all 50 consecutive patients without subsequent failure or significant complications with a maximum follow-up of 4 years. One patient had recurrent stress urinary incontinence and two had asymptomatic cystoceles. Three patients had erosion of monofilament sutures at the vaginal apex. CONCLUSIONS: In these 50 patients with significant complex uterine or vaginal vault prolapse, uterosacral ligaments could always be identified and safely used for vaginal vault suspension by the vaginal route with no persistence or recurrence of vaginal vault prolapse 6 to 48 months after surgery. Excessive tension by the surgeon on tagged uterosacral ligaments at the time of hysterectomy may be an etiologic factor in vaginal vault prolapse.     

Experience and results of application of remote afterloading system (RALS) optimization program for intracavitary treatment of squamous cell carcinoma of the uterine cervix

An optimization program for a remote after-loading system (RALS) for intracavitary treatment of cancer of the uterine cervix was established in 1982 by Tabushi and his co-workers. This system has been used in our hospital since 1986, using MODULEX. Seventy-three cases of untreated squamous cell carcinoma of the uterine cervix have been treated under RALS, 29 under conventional RALS and 44 under the RALS optimization program. The cumulative 5-year survival rates were obtained for the groups treated under each system by the Kaplan-Meier method. The 5-year survival rate of stage II cases treated under the RALS optimization program was 68.2%, and that of stage III cases 58.5%. On the other hand, that of stage II cases treated under conventional RALS was 56.3%, and that of stage III cases 44.9%. There was no significant difference between these two groups. Local control rates for stage II and III cases were higher than 5 year-survival rates. Among complications, the frequency of grade 2 radiation colitis was 15.9% with the RALS optimization program cases, and that of grade 2 radiation cystitis was 4.5%. We consider the RALS optimization program to be a clinically useful method for the intracavitary treatment of squamous cell carcinoma of the uterine cervix.     

Memory modulation by post-training glucose or insulin remains evident at long retention intervals

We started photodynamic therapy in gynaecologic tumors in 1988. Seven patients with endometrial carcinomas stage FIGO 1a (restricted to the endometrium) were treated primarily and also 4 patients with recurrences of vaginal and vault cervix carcinoma, carcinoma of the corpus uteri and the vulva. Residual tumors after conventional therapy of cervix and vulvar carcinoma were treated in 2 patients. Tumor illumination was performed by an Argon dye laser 24-72 h following the intravenous administration of haematoporphyrin derivatives (HPD) (Photosan III, 2 mg kg-1 body weight). The intracavitary tumor irradiation by means of a glass fibre was controlled by ultrasound. Superficial and small lesions of vaginal and vulvar carcinomas were subjected to superficial light irradiation; whereas tumors exceeding 1 cm in depth were treated interstitially. Tumor response was estimated 1 month after therapy. Complete remission was achieved in 8 patients, partial remission in 2, and no remission in 3 cases. Subsequent radiotherapy was performed in 3 patients with bleeding endometrial cancer with consecutive complete response.     

Unindicated preoperative testing: ASA physical status and financial implications

Adenoid basal carcinoma of the uterine cervix is rare and its cell origin is still obscure. We report a case of adenoid basal carcinoma of the uterine cervix discovered incidentally in a 69-year-old woman who had been hysterectomized due to endometrial adenocarcinoma of the uterine corpus. Histologically, small round-to-oval cancer cell nests with peripheral cell palisading were seen budding from the basal cell layer of the uterine cervix showing carcinoma in situ. Immunohistochemically, the basaloid cells of the adenoid basal carcinoma were positive for keratins 14, 17 and 19 and resembled reserve cells of the cervical epithelium. The results of this study clearly demonstrated that adenoid basal carcinoma shows a phenotype similar to reserve cells of the uterine cervix. A review of the literature indicated that this tumor has a favorable prognosis and should be clearly separated from adenoid cystic carcinoma, which has a much poorer outcome.     

Thrombosis following hip arthroplasty. A study using phlebography and 125I-fibrinogen test

The rate of incidence and morphology of metastases in 284 Fallopian tubes from 148 patients with primary uterine corpus cancer have been investigated. In 44 patients metastases were discovered in inner organs, of which in 17 (11.5% patients) in 23 oviducts. In 10 of these patients the Fallopian tubes were the only localization of metastases. Macroscopical alterations in the form of thickening and condensation, tumor nodules on the surface of the affected oviducts were discovered in 7 cases. In the remainder no macroscopical changes have been noted. There predominated lymphogenic metastases, in a smaller number of cases there were implantation and lymphogeno-implantation type metastases, localized mostly in the ampullary regions of the oviducts. More often, one could observe involvement by lymphogenic metastases of the subserosal layers together with muscular tissue, less frequently of mucosal layers, and total involvement of all layers of the wall of Fallopian tubes in the form of single or multicentric tumor nests, or diffuse tumor infiltration of tissues of the oviduct wall. Implantation metastases in the form of micronodules, multicellular agglomerates were discovered on the serosa more often than on the mucosa of Fallopian tubes. Secondary oviduct carcinomas differ from primary ones by their histological structure and character of growth. The Fallopian tubes play an essential role in the dissemination of metastases in the presence of primary uterine corpus carcinoma.     

The combined method: a novel access technique for fetal endoscopic surgery

BACKGROUND/PURPOSE: To develop practical and less invasive techniques for fetal endoscopic surgery, new methods of lifting the uterine wall to allow fetal surgery without maternal laparotomy were developed and assessed. METHODS: Fetal endoscopic surgical procedures, including tracheostomy and umbilical vascular cannulation, were performed using one of the three methods to enter the uterus without maternal laparotomy in pregnant goats (n = 6; 105 to 115 days' gestation): (1) direct uterine lifting with an air-cushion device; (2) indirect uterine lifting, in which the uterine wall was fixed to the maternal abdominal wall using balloon tip ports inserted percutaneously by Seldinger's method, then the maternal abdomen was lifted mechanically; and (3) combined method, in which low pressure CO2 (5 mm Hg for initial inflation and 2 mm Hg for maintenance) was insufflated into the uterus in addition to the indirect uterine lifting cited above. RESULTS: The direct uterine lifting caused massive injury of myometrium and uterine membranes. The creation of intrauterine space and the protection of the membranes were not accomplished effectively by the indirect uterine lifting only. The combined method provided the adequate intrauterine space and excellent endoscopic visibility for completion of the endoscopic procedures with minimal uterine injury. CONCLUSION: The fetal endoscopic surgery may be accomplished simply and safely by the combined method, a novel technique of uterine lifting to allow fetal surgery without maternal laparotomy.     

Successful peer review of courses: a case study

PURPOSE: In patients with early cervix carcinoma, both radiotherapy and surgery or combined modalities provide effective therapies. In the two last modalities, recommended surgery is radical hysterectomy. The purpose of this prospective study was to assess the value of a limited vaginal hysterectomy after brachytherapy in patients without any unfavorable prognostic factor. PATIENTS AND METHODS: Twenty-two patients (stage Ia2 with vascular invasion: three patients, stage Ib 1:19 patients) with 1 cm median maximal tumor size and with previous negative laparoscopic lymphadenectomy (median number of lymph nodes: 12) underwent a limited vaginal hysterectomy 6 weeks after utero-vaginal brachytherapy. RESULTS: Two mild intra-operative complications were noted. Venous hemorrhage (100 mL) occurred in one patient during lymphadenectomy and another patient presented bladder injury during hysterectomy. These two complications were successfully controlled with no need for laparotomy. Only one late complication was observed: bladder grade G2 (b). With a 29 months follow-up (20-48 months), no recurrence was reported. CONCLUSION: These results appear promising in patients with very early cervix carcinoma but remain to be confirmed on a larger scale.     

Colposcopy images of cervix in women with Gardnerella vaginalis infection

Among micro-organisms infecting vagina whose dominant genus is GV anaerobic bacteria are often present. There are reports that GV infections of vagina and uterine cervix, apart from their well-known negative role in obstetrics practice can play a role in carcinogenic processes of uterine cervix. The aim of the study was to assess characteristic colposcopy images of cervix in women with Gardnerella vaginalis infection. The research was carried out on 1180 women hospitalised in the period of 14 months. Many observations lead to conclusions that pathognomic clinic feature of Gardnerella vaginalis infection of uterine cervix is visible in colposcope presence of clean, translucent mucus in external cervical os and opaque vaginal contents in the rear vaginal vault. High hydrogen ion concentration in vaginal contents (pH 6.0 and over) correlates with positive "fishy odour test" of this contents. Gardnerella vaginalis infection of vagina and uterine cervix concerns women with existing erosion-type changes of uterine cervix. Visible in colposcopic test restless and "spotted" images visible after Schiller test are pathognomic colposcopic features of Gardnerella vaginalis infection.     

Expression and induction by IL-6 of the normal and variant genes for human plasminogen

A disposable suturing instrument is used in our surgical method for sacrospinous vault suspension to facilitate suture placement and retrieval. The pararectal space is dissected and the suturing device is placed just medial to the lateral third of the sacrospinous ligament-coccygeus muscle complex. Depression of the device's firing button advances a standard needle in a controlled circular path through the sacrospinous ligament-coccygeus muscle complex. The needle is retrieved with a straight-needle holder at a consistent location, 3 mm from the shaft of the instrument. A second suture is placed 0.5-1 cm medial to the first suture. If the holding strength for either suture is considered inadequate, the device is reloaded with the same suture and subsequent bites are taken. The procedure is completed using standard methods. In ten women treated for vaginal vault eversion, lateral dissection was completed in less than 10 minutes, and passage of two sutures through the sacrospinous ligament was accomplished in less than 2 minutes. There were no complications. One patient described mild buttock pain that resolved in 1 week. At 4-6 months' follow-up, vaginal examination with maximal straining demonstrated direct apposition of the vaginal wall to the sacrospinous ligament.     

Antibody-targeted radio-chemotherapy of human primary liver cancer with radio-iodinated AFP monoclonal antibodies conjugated with mitomycin C: a preliminary clinical observation

Our study was carried out on 70 patients with invasive squamous carcinoma of the uterine cervix (CC) or invasive adenocarcinoma of the uterine cervix at all stages, admitted to the University Department of Gynecology and/or to the Institute of Oncology in Ljubljana. The patients were not selected by age. A questionnaire on known risk factors in CC was filled in for each of the 70 patients, and two tumor smears were taken for the determination of human papilloma viruses (HPV) 16 and 18 by means of in situ hybridization and polymerase chain reaction (PCR). Each patient also had the serum level of vitamin A determined. The results of our study revealed a correlation between HPV 16 or 18 infection (60:40) and CC. When analysing some already known risk factors, no statistically significant difference could be established for any of the factors studied, except for the age at first birth.     

Pseudocystic metastases of carcinoma of the uterine cervix mimicking polycystic liver disease

Pseudocystic liver metastases are rare and mainly described in neuroendocrine or ovarian tumors. We report the case of a 46-year-old woman who presented with multiple hepatic metastases mimicking polycystic liver disease. Carcinoma of the uterine cervix had been diagnosed 9 years earlier, and initially treated by radiumtherapy and surgery. Although histological post mortem examination of the pseudocystic liver metastases was not characteristic, they were related to the uterine cervix carcinoma for the following reasons: no other primary tumor was discovered, especially carcinoid or ovarian tumors: immunostains were positive for epithelial cells and negative for the neuroendocrine panel: the cystic cerebellum metastasis had a typical histologic aspect. Uterine cervical carcinoma must thus be included in the list of tumors which may form cystic hepatic metastases.