The impact of prenatal and neonatal infection on neurodevelopmental outcomes in very preterm infants.

OBJECTIVE: Determine the association of prenatal and neonatal infections with neurodevelopmental outcomes in very preterm infants. STUDY DESIGN: Secondary retrospective analysis of 155 very preterm infants at a single tertiary referral center. General linear or logistic regression models were used to evaluate the association with hospital factors; brain injury, growth and development; and neurobehavioral outcome. RESULT: Necrotizing enterocolitis with sepsis was associated with reduced transcerebellar diameter (38.3 vs 48.4 mm, P<0.001) and increased left ventricular diameter (12.0 vs 8.0 mm, P=0.005). Sepsis alone was associated with higher diffusivity in the left frontal lobe (1.85 vs 1.68 × 10⁻³ mm² s⁻¹, P=0.001) and right cingulum bundle (1.52 vs 1.45 × 10⁻³ mm 253 s⁻¹, P=0.002). Neurobehavioral outcomes were worse in children exposed to maternal genitourinary infection (cognitive composite: ß=-8.8, P=0.001; receptive language score: ß=-2.7, P<0.001; language composite: ß=-14.9, P<0.001) or histological chorioamnionitis (language composite: ß=-8.6, P=0.006), but not neonatal infection. CONCLUSION: Neonatal infection was associated with changes in brain structure but not with neurobehavioral outcomes, whereas the opposite pattern was observed for maternal genitourinary tract infection. These findings emphasize the potential importance of infections during pregnancy on the neurodevelopmental outcomes of preterm infants.

Placental pathology, first-trimester biomarkers and adverse pregnancy outcomes.

OBJECTIVE: We investigated the relationship between placental pathological findings in pregnancies with adverse pregnancy outcomes and first-trimester serum analytes and uterine artery Doppler results. STUDY DESIGN: This is a secondary analysis of a prospective study of first-trimester screening for adverse pregnancy outcomes, including preterm birth (PTB (delivery<37 weeks)), pre-eclampsia (PE), gestational hypertension, and small for gestational age (SGA) infants (birth weight <10th percentile). We compared the mean levels of serum analytes (pregnancy-associated plasma protein A (PAPP-A), placental protein 13 (PP13), a-disintegrin and metalloproteinase 12 (ADAM12), placental growth factor (PLGF)) and uterine artery Doppler pulsatility index (UADPI) obtained between 11 and 14 weeks gestation in cases with adverse outcomes and abnormal placental histology to a control group without adverse outcome or abnormal placental pathology. Placental findings were classified as: lesions of maternal under perfusion, lesions causing reduced placental reserve, infections/inflammatory lesions, and fetal vascular lesions. RESULT: Among 193 cases, lesions of maternal under perfusion were seen in 50 cases (25.9%), lesions causing reduced placental reserve in 63 cases (32.8%), infection/inflammation in 65 cases (34.2%) and fetal vascular lesions in 23 cases (11.9%). There were 123 pregnancies with no adverse pregnancy outcome or placental lesion used as controls. Pregnancies with PE had a significant association with lesions of maternal under perfusion (P=0.005) and placental infection/inflammation (P=0.003). Significant differences were seen in mean levels of PAPP-A, ADAM12 and PLGF in cases with PE, PTB and SGA with specific placental histological findings when compared with controls. UADPI was not significantly different between the cases with adverse pregnancy outcomes and abnormal histology. CONCLUSION: Our findings provide evidence linking placental pathology with suboptimal secretion of analytes in the first trimester in pregnancies with adverse outcomes, especially PE.

Placental pathologic aberrations in cases of familial idiopathic spontaneous preterm birth.

OBJECTIVE: To test the hypothesis that placental histologic characteristics in familial spontaneous preterm birth (sPTB) differ by gestational age (GA) and reflect possible mechanisms of pathogenesis. STUDY DESIGN: Secondary analysis from prospective cohort study in women with sPTB <35 weeks and a first degree family member with PTB. Placental specimens (n = 79) were categorized by maternal and/or fetal inflammatory response (MIR, FIR) and compared among three preterm GA categories. RESULTS: Inflammatory changes were common. MIR was most frequent at the earliest GAs, 85% with PTB <28 weeks [(adj)OR 77.5 (95% CI 5, 1213.1)], and 57% at 28-32 weeks [(adj)OR 6.1 (0.8, 48.5)] compared to later PTBs occurring at 32-35 weeks (22%). FIR also occurred most frequently in the earliest cases of PTB <28 weeks. CONCLUSIONS: Placental inflammatory responses are common in women with familial sPTB. This data suggests that inflammation plays an important role in the onset of parturition in cases otherwise classified as idiopathic or spontaneous in nature, especially at the earliest GAs when neonatal outcomes are the poorest.

Aberrant promoter methylation and silencing of the POU2F3 gene in cervical cancer.

POU2F3 (OCT11, Skn-1a) is a keratinocyte-specific POU transcription factor whose expression is tied to squamous epithelial stratification. It is also a candidate tumor suppressor gene in cervical cancer (CC) because it lies in a critical loss of heterozygosity region on 11q23.3 in that cancer, and its expression is lost in more than 50% of CC tumors and cell lines. We now report that the loss of POU2F3 expression is tied to the hypermethylation of CpG islands in the POU2F3 promoter. Bisulfite sequencing analysis revealed that methylation of specific CpG sites (-287 to -70 bp) correlated with POU2F3 expression, which could be reactivated with a demethylating agent. Combined bisulfite restriction analysis revealed aberrant methylation of the POU2F3 promoter in 18 of 46 (39%) cervical tumors but never in normal epithelium. POU2F3 expression was downregulated and inversely correlated with promoter hypermethylation in 10 out of 11 CC cell lines. Immunohistochemical analysis on a cervical tissue microarray detected POU2F3 protein in the epithelium above the basal layer. As the disease progressed, expression also decreased, especially in invasive squamous cell cancer (70% loss). Thus, aberrant DNA methylation of the CpG island in POU2F3 promoter appears to play a key role in silencing this gene expression in human CC. The results suggested that POU2F3 might be one of the CC-related tumor suppressor genes, which are disrupted by both epigenetic and genetic mechanisms.

Late recurrence of malignant melanoma presenting as peritoneal "carcinomatosis".

Malignant melanoma is a relatively rare malignancy that arises from melanocytes and accounts for approximately 1% of all malignancies reported in the United States. Malignant melanoma can develop in any part of the skin or mucosal membranes. It metastasizes to all organs of the body and often demonstrates unpredictable metastatic behavior. Late recurrence of malignant melanoma, defined as occurring 10 or more years after diagnosis and treatment, is a rare but characteristic metastatic behavior of malignant melanoma. We present a case of a late recurrence of malignant melanoma presenting with diffuse peritoneal studding.

Trichofolliculoma of the vulva associated with vulvar intraepithelial neoplasia: report of three cases and review of the literature.

Trichofolliculoma is an uncommon, benign cutaneous adnexal neoplasm most commonly occurring on the head and neck. Trichofolliculoma of the vulva has not been previously reported. The juxtaposition of a trichofolliculoma in an excisional biopsy specimen performed for vulvar intraepithelial neoplasia (VIN III) created a diagnostic dilemma and prompted a review of our files from 1989 to 2000 for additional cases. A search for benign hair follicle tumors of the vulva identified two additional trichofolliculomas. All three vulvar trichofolliculomas were associated with VIN III. During this same period, 628 cases of vulvar intraepithelial neoplasia II and III were identified. The appearance of trichofolliculoma at this previously unreported site may present diagnostic difficulty.

Loss of heterozygosity at 11q23.3 in vasculoinvasive and metastatic squamous cell carcinoma of the cervix.

We have previously demonstrated a strong relationship between loss of heterozygosity (LOH) at chromosome 11q23.3 and the presence of extensive tumor plugs in lymphvascular spaces (LVS) in stage 1B cervical carcinoma, suggesting that genes at this locus may regulate vasculoinvasion. This study examined LOH at 11q23.3 in microdissected tumor plugs within LVS and in metastatic foci in lymph nodes (MFLN), as well as corresponding invasive tumor and adjacent cervical intraepithelial neoplasia (CIN) 3 in stage 1B squamous cell carcinoma. Of 49 invasive carcinomas, 38.8% had LOH at 11q23.3. Of 36 tumor plugs in LVS, 39% had LOH at 11q23.3. Twenty percent of 15 MFLN demonstrated LOH at 11q23.3. Patients with LOH at 11q23.3 are significantly more likely to have disease recurrence than patients without LOH at 11q23.3 (P =.02). Of 10 foci of CIN 3, none showed LOH at 11q23.3. Although unlikely to have an impact early in carcinogenesis, tumor-suppressor genes located in the region of 11q23.3 appear to be important in tumor progression, facilitating lymphvascular space invasion and, by inference, spread to lymph nodes in squamous cell carcinoma of the cervix.

h-Caldesmon expression effectively distinguishes endometrial stromal tumors from uterine smooth muscle tumors.

Distinction of endometrial stromal neoplasms from cellular smooth muscle tumors of the uterus is sometimes difficult. Immunohistochemistry is often not helpful because muscle actins and desmin are expressed in both neoplasms. This study's goal was to determine whether h-caldesmon, a smooth muscle-specific isoform of a calcium, calmodulin, and actin binding protein, could effectively distinguish endometrial stromal tumors from uterine smooth muscle tumors. The authors analyzed immunohistochemical expression in 24 endometrial stromal neoplasms (21 sarcomas and three nodules), 29 leiomyosarcomas, 32 leiomyomas (10 "usual," 14 cellular leiomyoma, and eight "highly cellular" types), 40 myometria, and 25 endometria. h-Caldesmon was diffusely positive in all myometria, leiomyomata, and leiomyosarcomas. Of note, 16 leiomyosarcomas (55%) were positive for h-caldesmon in more than 50% of tumor cells. In five "highly cellular" leiomyomas, h-caldesmon expression was markedly decreased or absent in areas morphologically resembling endometrial stromal tumors, raising the possibility that these tumors may be mixed smooth muscle-endometrial stromal neoplasms. In contrast, h-caldesmon expression was absent in all endometria and endometrial stromal neoplasms apart from accompanying small vessels. Desmin was diffusely positive in all myometria and leiomyomata. The fraction of cells expressing desmin was greater than that of h-caldesmon in only 10% of leiomyosarcomas. Focal desmin expression was also present in eight of 25 (32%) endometria and 12 of 24 (50%) endometrial stromal neoplasms. h-Caldesmon appears to be a more sensitive and specific marker of smooth muscle differentiation in the uterus than desmin and may be a useful tool for distinguishing and classifying uterine mesenchymal tumors.

Cervical cancer suppressor gene is within 1 cM on 6p23.

We previously showed loss of heterozygosity at 6p to be a common genetic alteration in cervical cancer and cervical intraepithelial neoplasia. To characterize this critical area of deletion in chromosome 6, we evaluated 107 invasive cervical cancers, using 23 polymorphic markers. Genomic DNA from microdissected frozen or paraffin-embedded cervical tumors and corresponding normal tissue was analyzed. Fifty-three percent (57/107) of the cervical tumors showed loss in 6p. Deletions were found in all stages and histologic types. Ninety-one percent (52/57) of these tumors had a loss at 6p23. One tumor defined the distal area of deletion at marker D6S429. Two tumors defined the proximal area of deletion at marker D6S1578. Genotyping of parental DNA was done on 16 cases to evaluate the origin of chromosomal loss. The deletion occurred in the paternal chromosome in 10 tumors and in the maternal in six. Within each tumor, the same parental chromosome was lost at all tested heterozygous 6p markers. The order of the polymorphic markers and estimate of distances in the critical region were confirmed by generation of a yeast artificial chromosome (YAC) contig and pulse-field gel electrophoresis. Our data strongly suggest that a gene important in cervical cancer tumorigenesis is located within a 1-cM region of 6p23, and it is not imprinted.

Association between DQB1 and cervical cancer in patients with human papillomavirus and family controls.

OBJECTIVE: The role of human leukocyte antigen (HLA) DQB1 alleles and human papillomavirus (HPV) as contributing factors to invasive cervical cancer was investigated. To overcome problems of misleading causal inferences common in traditional case-control studies, a family-based test, the transmission/disequilibrium test, was used. METHODS: Ninety-six patients with pathologically confirmed invasive cervical cancer were ascertained. Human papillomavirus types were determined in 80 patients, of whom 81.25% were HPV-positive, and 18.75% were HPV-negative. Deoxyribonucleic acid was extracted from samples, taken from patients and their parents, and sequenced to determine DQB1 genotypes. Nuclear family data were used to test whether the DQB1 locus is associated with invasive cervical cancer while controlling for high-risk HPV-positive patients. The transmission/disequilibrium test evaluates whether the frequency of transmission of parental marker alleles to their affected offspring deviates from the expected Mendelian frequency of 50%. RESULTS: The HLA DQB1 locus showed evidence for allelic association with invasive cervical cancer in high-risk HPV-positive patients (P = .006). The transmission/disequilibrium test showed that the DQB1*0303 allele was transmitted to high-risk HPV patients more often than expected by chance, chi2(1) = 8.0, P = .005 (P = .035 when correcting for multiple tests). Tests of association were negative when applied to all 96 patients, irrespective of HPV status. No significant differences were found in the distribution of the DQB1 alleles among HPV-positive patients compared with those who were HPV-negative, indicating that HLA alleles are not associated with susceptibility to HPV infection. CONCLUSION: These results suggest that the DQB1*0303 allele increases the risk for invasive cervical cancer in women who are HPV-positive.

Idiopathic calcinosis cutis presenting as labial lesions in children: report of two cases with literature review.

BACKGROUND: Calcinosis cutis is a general term for calcium deposition in the skin. It may be due to abnormal calcium or phosphorus metabolism, damage to the dermal collagen, or idiopathic. It has been found in the skin of many areas of the body, including the face, extremities, penis, scrotum and mons pubis. We report two cases of calcinosis cutis presenting as lesions of the labia majora in children. CASES: A 6 1/2-year-old girl presented with labial lesions of unknown etiology. There was no history of sexual abuse or trauma. Excisional biopsy was performed and histopathological evaluation showed subepithelial calcification. Follow-up laboratory evaluation revealed normal serum calcium and phosphorus levels. Screening tests for collagen vascular diseases were negative. An 8-year-old girl presented for evaluation of a "labial cyst." The lesion was first noted 6 months prior to presentation and had not resolved, despite treatment with topical creams and sitz baths. Excisional biopsy was performed and histopathological evaluation showed multiple nodules of calcified and amorphous debris surrounded by histiocytes and giant cells. CONCLUSION: We report two cases of idiopathic calcinosis cutis presenting as labial lesions in children. Because it can be mistaken for a sexually transmitted disease, recognition and proper diagnosis of this condition is essential. Additionally, work-up to rule out abnormalities of phosphorus or calcium metabolism and collagen vascular diseases may be indicated.

Desmoplastic small round cell tumor of the abdomen: radiologic-histopathologic correlation.

PURPOSE: To characterize the imaging features of desmoplastic small round cell tumor of the abdomen and correlate them with the histopathologic findings. MATERIALS AND METHODS: Eleven of 14 patients with desmoplastic small round cell tumor had primary abdominal involvement. In nine of these patients (mean age, 20 years), results of imaging studies (computed tomography in nine patients, ultrasonography [US] in three) and histopathologic specimens were retrospectively analyzed. RESULTS: The hallmark imaging feature was lobulated peritoneal masses (mean number, 4.4; range, 1-17) with a mean diameter of 5.0 cm (range, 2-12 cm). Omental and paravesical tumors were each present in six patients. Retroperitoneal masses were present in three patients. The tumors were well defined and hypoechoic at US. Heterogeneity due to tumor hemorrhage or necrosis was seen in seven patients. Ascites was present in five patients. Parenchymal and/or serosal hepatic metastases, punctate calcifications, nodular peritoneal thickening, lymphadenopathy, hydronephrosis, and bowel obstruction were less common associated findings. CONCLUSION: Bulky peritoneal soft-tissue masses without an apparent organ-based primary site are characteristic of intraabdominal desmoplastic small round cell tumor. Although the findings are nonspecific, this diagnosis can be considered in adolescents and young adults with characteristic imaging findings.

Loss of heterozygosity in clinical stage IB cervical carcinoma: relationship with clinical and histopathologic features.

Loss of heterozygosity (LOH) has been shown to be an important prognostic factor in a variety of malignant neoplasms. The relationship between LOH and established histopathological prognostic factors in cervical carcinoma has not been examined. We studied LOH in 58 FIGO stage IB cervical cancers treated by radical hysterectomy. In a randomly selected subset of 37 of these cases, LOH was examined using markers for all 41 chromosomal arms. Seventy-six percent of the 58 cases and 95% of the extensively studied cases showed LOH at one or more loci. The three most common sites of LOH were 3p21, 6p24-p23, and 11q23.3. In the extensively studied group, LOH on 11q was associated with extensive lymphvascular space invasion (P = .009) and less deeply invasive tumor (P = .042). There was a trend for tumors with LOH on 11q to recur, but this was not statistically significant. No correlation between the presence of LOH on 3p or 6p and lymphvascular space invasion or tumor depth was present. There was no correlation between the number of sites of LOH or between the presence of LOH on 3p, 6p, and 11q and the presence of metastatic tumor in regional lymph nodes, histologic type (squamous v nonsquamous), tumor differentiation, maximum tumor size, degree of inflammation, pattern of invasion, mitotic rate, or clinical recurrence. In summary, tumors with 11q LOH may behave in a more aggressive fashion. Future studies of LOH in cervical carcinoma should include histopathological prognostic information so that the relationship between LOH and these factors can be determined on larger numbers of patients.

Cervical intraepithelial neoplasia III shows frequent allelic loss in 3p and 6p.

We have shown previously that a significant number of invasive cervical cancers (ICC) have nonrandom chromosomal losses in 3p, 6p, 11q, 2q, 6q, and 19q, thereby suggesting that genes involved in the suppression of tumor development or progression are located in these regions. Cervical intraepithelial neoplasia (CIN) III is considered the precursor lesion for ICC of squamous type and occurs frequently with ICC of glandular type. In an effort to define which chromosomal losses are present in the precursor lesions, we identified CIN III lesions from 24 ICC treated by radical hysterectomy. Thirty-three CIN III associated with 22 squamous carcinomas and 2 adenocarcinomas were carefully microdissected from the paraffin-embedded sections. The whole genomic DNA from CIN III was amplified with short random primers. DNA from ICC, CIN III, and normal tissue was analyzed at the six chromosomal regions with polymorphic markers. Thirty-eight percent of hysterectomy specimens had loss of heterozygosity (LOH) in at least one of the CIN III lesions from each case. Loss occurred in 30% of cases in 3p14.1-12 (37% for associated ICC), 21% in 6p23 (33%), 14% in 2q33-37 (27%), 0 in 11q23.3 (33%), 4% in 19q13.4 (13%), and 0 in 6q21-23.3 (18%). These results suggest that mutations in 3p and 6p are important early in tumorigenesis, whereas 11q and 6q contain genes important later in tumor progression. Invasive and preinvasive cervical lesions appear to develop from multifocal genetic events since consistent losses do not occur within all precursor lesions in the same patient.

Allelotyping of all chromosomal arms in invasive cervical cancer.

The best characterized factor in the development of cervical cancer is the integration, of human papillomavirus into cervical cell chromosomes. In addition to HPV integration, the neoplastic process probably requires the activation of cellular protooncogenes and loss of tumor suppressor gene function. Loss of heterozygosity analysis in a large sample is used to identify regions which harbor putative tumor suppressor genes (TSG) since the deletion of normal alleles unmask mutated alleles. We evaluated tumor tissue from invasive cervical carcinomas, carefully microdissected to eliminate normal stroma and lymphocytes, for LOH at all 41 chromosomal arms with 50 polymorphic markers. We have evaluated tumor and normal DNA pairs from 48 invasive cervical cancers of which 85% of the tumors are confined to the cervix. The mean loss for all chromosomal arms was 12%. Three regions exhibited LOH two standard deviations above the mean: 3p14.1-12 (40%), 11q23.3 (36%), and 6p22-21.3 (32%). Three regions showed loss one standard deviation above the mean: 19q13.4 (30%), 6q21-23.33 (25%), and 2q33-37 (24%). Our results indicate that a significant number of invasive cervical cancers have lost specific chromsomal regions, thereby suggesting that genes involved in the cell cycle regulation or the suppression of tumor development are located in these regions.

Human complement regulator expression by the normal female reproductive tract.

BACKGROUND: The membrane-associated proteins that regulate human complement activation are ubiquitously expressed and function cooperatively to protect cells from autologous complement damage. For classical and alternative pathways, the primary regulators at the stage of C3 proteolysis and deposition are membrane cofactor protein (MCP; CD46) and decay-accelerating factor (DAF;CD55), whereas protectin or CD59 regulates terminal component assembly. There is increasing awareness in reproductive, tumor, and transplantation immunology of the conventional and non-complement roles of these proteins. The human reproductive system may serve as a model of the non-complement functions. METHODS: We performed immunohistochemical analyses of multiple normal ovaries, fallopian tubes, cervices, and uterine corpi by using well-characterized monoclonal antibodies to provide a detailed, direct comparison of complement regulator expression. RESULTS: Membrane cofactor protein was diffusely and strongly expressed on all epithelia and vascular endothelium and was the predominant regulator on oocytes. In contrast, decay-accelerating factor had variable expression in intensity and distribution on epithelia and was notably absent on certain epithelia and oocytes. It was the only regulator present on the connective tissue between muscle bundles in the myometrium and the cervix and was found on most stroma. CD59, although staining intensity varied, was present on virtually all epithelia, vascular tissue, and stroma. CONCLUSIONS: Distinct reproducible patterns of complement regulator expression are found throughout the female reproductive tract. Differential expression on certain epithelia and oocytes may suggest non-complement activities. This comprehensive study should provide a basis for further characterization of pathological tissues and mechanisms of cellular localization.

Local staging of endometrial carcinoma: comparison of transvaginal and intraoperative sonography and gross visual inspection.

OBJECTIVE: The purposes of this study were to compare transvaginal sonography (TVS), intraoperative sonography (IOS), and gross visual inspection of the uterus with the histopathologic findings in patients with endometrioid adenocarcinoma, and to compare the accuracies of TVS, IOS, and gross visual inspection in staging of the tumor. SUBJECTS AND METHODS: Sixteen patients with endometriod carcinoma were prospectively evaluated with TVS and IOS. Intraoperative gross visual inspection was also performed. Gray-scale, duplex, and color Doppler findings were used to stage patients. The location and depth of myometrial invasion and the presence of cervical involvement were recorded. At gross visual inspection, only the absence or presence and the depth of myometrial invasion (< or = 50% or >50%) were recorded. The data were analyzed three ways. First, in uterine specimens with myometrial invasion, a site-by-site comparison was made among the TVS and IOS findings and the final histologic results regarding location and depth of tumor invasion. Next, to determine tumor stage, myometrial invasion was defined in two ways: (1) absent, 50% or less, or greater than 50%; and (2) 50% or less or greater than 50%. Then imaging findings, gross visual inspection, and the final histologic results were compared. RESULTS: Of the 16 uterine specimens, eight had myometrial invasion, with 13 separate sites of tumor invasion. IOS correctly identified the location and depth (+/- 10% of the histologic depth) of tumor invasion at four (31%) sites, and TVS at one (8%) site. TVS and IOS overestimated myometrial invasion due to adenomyosis, bulky intraluminal tumor, and lymphovascular invasion. When myometrial invasion was defined as absent, 50% or less, or greater than 50%, TVS was correct in 60% of cases, IOS in 56%, and gross visual inspection in 53%. When myometrial invasion was defined as 50% or less or greater than 50%, TVS was correct in 93% of cases, IOS in 81%, and gross visual inspection in 80%. CONCLUSION: TVS and IOS are inaccurate in predicting the precise location and depth of myometrial tumor invasion. However, when a less rigorous definition of invasion is used, the accuracies of TVS and IOS are comparable to gross visual inspection in staging of the tumor.

Spontaneous uterine rupture and hemoperitoneum in the first trimester.

Uterine rupture, a potentially catastrophic complication during pregnancy, has been reported to occur spontaneously in the second and third trimesters. We describe a case of spontaneous uterine rupture at 8 weeks' gestation in a 29-year-old woman, who has a history of systemic lupus erythematosus. The diagnosis was established with the aid of ultrasound imaging. She underwent local excision of the perforated area of the uterus. Histologic examination revealed exuberant intermediate trophoblast. On follow-up, human chorionic gonadotropin (hCG) titers returned to normal over a 15-week period. We conclude that spontaneous uterine rupture can occur in the first trimester, and early utilization of ultrasound could help in the management of this serious condition.