Outpatient loop diathermy conization as an alternative to inpatient knife conization of the cervix.

A knife cone biopsy of the cervix is usually performed as an inpatient procedure under general anesthesia and is associated with significant morbidity. Loop diathermy conization was performed under local anesthesia on colposcopy outpatients as an alternative to knife conization. In 33 consecutive patients studied the procedure was well tolerated, there were no operative complications, and a satisfactory specimen for histologic examination was obtained in every case. One case of unsuspected invasive cancer and two of suspected microinvasive cancer were diagnosed. The diagnosis of cervical precancer was made in 24 (73%) of the cases. The introduction of outpatient loop diathermy conization of the cervix instead of knife conization would decrease hospitalization costs, avoid the need for general anesthesia and potentially reduce short-term patient morbidity.

En bloc radical vulvectomy and lymphadenectomy with modifications of separate groin incisions.

A new modification of radical vulvectomy and lymphadenectomy through separate groin incisions involves dissection of the intervening skin bridge and allows an en bloc dissection. The results in 26 women treated with this technique are compared with those of seven treated with separate incisions without an en bloc dissection. All 33 women had squamous carcinoma of the vulva and were treated between 1985-1989. The incidence of advanced disease was high, with nodal metastases present in 52% of cases. Dissection of the tissue beneath the skin bridge did not alter the morbidity of the procedure in terms of the incidence of wound infection, number of units of blood transfused, or duration of hospitalization. The only case of an isolated recurrence in the skin bridge occurred in a woman who did not have an en bloc dissection, although there was no significant difference in the overall local recurrence rate between the groups. Further evaluation with larger numbers is required, but we suggest that an en bloc dissection using separate incisions may reduce the risk of isolated recurrence in the skin bridge, particularly in patients with advanced disease.

Cytological screening history of patients with early invasive cervical cancer.

The value of population screening for cervical cancer has recently been questioned. The purpose of this study was to examine the cytological screening history in 100 consecutive patients undergoing Wertheim's hysterectomy for early invasive cervical cancer. Twenty three per cent of the patients were never screened; the screening history was unavailable in 11%; the patient was referred appropriately in 21%; there was a delay in referral for gynaecological assessment in 21%; the patient's previous cervical smear before referral was normal in 24%. If population screening in Ireland is to have an impact on mortality from cervical cancer, the results of this study indicate that greater attention needs to be given not only to extending the number of women screened, but also to increasing the frequency of screening and to improving the clinical response to an abnormal smear.

A clinical review of cervicography.

A new investigative modality, cervicography, has been advocated for cervical screening. In the first 51 patients referred for colposcopy because of an abnormal cervicogram, none had invasive cancer and 75% had preinvasive cancer. The cervicogram appears superior to cytology but inferior to colposcopy in the detection of cervical pathology. Based on the available evidence, however, cervicography cannot be recommended for universal screening. It may have a role in the follow-up of patients with a mildly abnormal cervical smear, but the optimum management remains early referral for colposcopy.

Correlation of colposcopy and histology findings in pre-clinical neoplasia of the cervix.

The histology findings of pre-clinical neoplasia of the cervix at cone biopsy were compared with the previous colposcopic assessment in fifty-eight patients. In 84.5% of cases colposcopy prediction was within one grade of the histology findings. This close correlation is important where suitability for local ablative therapy depends on accurate colposcopic assessment prior to tissue destruction.

Vaginal intraepithelial neoplasia: biologic aspects and management.

A review of 59 consecutive cases of vaginal intraepithelial neoplasia seen in a colposcopy clinic between 1971 and 1984 was made. All patients presented with an abnormal Papanicolaou smear, and diagnosis was confirmed by colposcopically directed biopsy. The patients ranged in age from 23 to 72 years, with a mean age of 49. Fourteen (24%) patients were less than 40 years of age. A previous hysterectomy had been performed in 68% of patients, 42.5% of these being for benign disease. Forty-two patients (71%) had evidence of multicentric neoplasia of the lower genital tract, and 30 (51%) had been treated previously for cervical neoplasia. Twenty-nine lesions were multifocal and 52 (88%) were located in the upper third of the vagina. The results of the different modes of treatment were reviewed. Surgical extirpation gave the best results. The local ablative techniques used, ie, electrocautery and CO2 laser, were associated with failure rates of 25 and 50%, respectively. Three patients developed invasive carcinoma of the vagina after treatment.

Clinical correlations of carcinoembryonic antigen in post-operative patients with epithelial ovarian cancer.

Plasma CEA as a tumor marker was studied in 681 postoperative patients with invasive epithelial cancer of the ovary. The sensitivity of a single CEA value was low in correlating with tumor burden, relapse status or in predicting subsequent relapse. The false negative rate was high. Serial samples were helpful in predicting relapse in a small number of patients where the value was persistently high. CEA showed greater sensitivity and prognostic value in patients with the mucinous tumor subtype, than other histologies. A clinically useful role for CEA is likely to be restricted to small subsets of patients, such as those with mucinous tumors where CEA may have a complementary role with other markers. A change in assay method during the course of the study resulted in a weakening of the value of CEA as a tumor marker.