A scoring system for predicting recurrence of cervical cancer.

An evaluation was made of factors that affect the recurrence of cervical cancer after primary surgery, these including age, clinical stage, histology, grade, involvement of uterine body, parametrium or vagina and lymph node metastases. During a period of at least 3 years, 702 of 1508 patients who underwent radical hysterectomy and pelvic lymph node dissection were studied by using a scoring system. A comparison between the group of women scored at or greater than 13 that scored less than 13 revealed that the risk of recurrence was higher in the former group. One hundred and twenty five of 702 patients found to have positive pelvic node involvement scored greater than 13, which rendered them eligible for further mangement as follows: the recurrence rate in 99 patients receiving multi-agent chemotherapy was 34.4%, compared with 65.4% in 26 patients receiving no treatment (P < 0.01). Applying this score to other patients in planning adjuvant therapy, the recurrence rate may be reduced further. The number of patients needlessly exposed to the toxic effects of multi-agent chemotherapy may be reduced also.

Modified pelvic anterior exenteration.

During a 20-year time period, 117 patients with various histologic types of cancer underwent pelvic exentereation. Six of the 107 patients who needed anterior exenteration with urinary diversion received partial excision of the urinary bladder and modification surgery, of which three had uretero-cystostomy, two had mobilization of bladder and uretero-cystostomy and one had uretero-uterostomy. These six patients, except for two, died of disease in 1 year. Two patients are alive and happy, with quality of life because they can urinate normally. We suggest that anterior exenteration should be modified whenever possible to preserve the bladder and not to do an urinary diversion.

Chemotherapy for ovarian mucinous cystadenocarcinoma during pregnancy: a case report.

There is limited experience in the treatment of epithelial ovarian malignancy with chemotherapy during pregnancy. We present the case of a 36-year-old women with ovarian mucinous cystadenocarcinoma during pregnancy, on whom exploratory laparotomy was performed at the gestational age of 16 weeks. Afterwards chemotherapy with cyclophosphamide (500 mg/m2) and cisplatin (50 mg/m2) was administered beginning at the second trimester of pregnancy due to surgical Stage Ic. Although preterm labor and a prematurely ruptured membrane occurred at the gestational age of 29 weeks before the fourth course of chemotherapy, there was still a satisfactory outcome for mother and fetus after an emergency cesarean section due to breech presentation at the gestational age of 30 weeks.

The distribution and differential risks of human papillomavirus genotypes in cervical preinvasive lesions: A Taiwan Cooperative Oncologic Group Study.

To clarify the distribution and relative risk of different human papillomavirus (HPV) genotypes in cervical preinvasive lesions, 1246 women with abnormal Papanicolaou smear including atypical squamous cell of unknown significance (ASCUS), atypical glandular cell of unknown significance (AGUS), low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion (HSIL) were enrolled in a multicenter, cross-sectional study. Colposcopy and HPV tests with hybrid capture 2 and polymerase chain reaction-reverse line blot were performed. The prevalences of HPV in ASCUS/AGUS-negative histology, ASCUS/AGUS, LSIL, HSIL, and invasive cancer were 33.8%, 38.3%, 74.9%, 84.3% and 100%, respectively, with an overall positive rate of 68.8%. The most common HPV types were HPV 16 (18.5%), 52 (16.5%), 58 (13.2%), 33, 51, 53, 18, 39, 59, 66, MM8, and 31. In comparing the relative risk of HPV infection in different disease status, LSIL and HSIL/carcinoma had a 4.64 (95% CI: 2.98-7.24) and 10.53 (95% CI: 6.69-16.58) folds of risk of high-risk HPV infection than the negative group. The same was true in mixed HPV infection, but not in low-risk type infection. Looking into each high-risk HPV type, the relative infection risks for LSIL and HSIL/carcinoma, in comparison with the negative group, were 1.67 (0.63-4.43) and 8.67 (3.46-21.70), 2017 (1.01-4.68) and 3.04 (1.42-6.47), and 1.40 (0.52-3.77) and 5.22 (2.07-13.19) for HPV type 16, 52 and 58, respectively. The study confirmed the high prevalence and risky nature of HPV 52 and 58 in Taiwanese population and conveyed the need to include these HPV types in vaccine development.

Human papillomavirus detection in adenocarcinoma and adenosquamous carcinoma of the uterine cervix in Taiwan.

BACKGROUND: The association of human papillomavirus (HPV) with cervical adenocarcinoma (ADC) and adenosquamous carcinoma (ADSC) is well documented. The relationship between HPV and the histopathology of ADC and ADSC is not clearly understood. This study proposed to evaluate: 1. the prevalence of HPV infection in cervical ADC and ADSC in Taiwan; 2. any correlation of HPV and histologic subtypes, grading and tumor staging of ADC and ADSC; 3. the possible role of HPV in cervical ADC and ADSC. METHODS: HPV detection was carried out using a non-isotopic in situ hybridization (ISH) technique on paraffin sections of 33 cervical ADC and 12 ADSC. An FITC-labelled probe of wide spectrum HPV was used for screening, and probes of HPV 6/11, 16, 18, 31, 33 were used for typing. RESULTS: Of the 33 cases of cervical adenocarcinoma, 15 (45%) were HPV positive; of these, 10 (30%) were HPV 18, and 4 (12%) were HPV 16. In ADSC, 7 (58%) cases contained HPV DNA, of which HPV 18 was detected in 2 (17%), and type 16 in 3 (25%). Unidentified HPV types were found in one and in two cases of ADC and ADSC, respectively. There were no significant correlations between HPV status and histologic subtypes, grading and tumor staging. All the HPV-positive ADC contained punctate nuclear HPV signals. In ADSC, the signal pattern was heterogeneous. HPV DNA was integrated in all but one viral positive cases. CONCLUSIONS: These results indicate that ADC and ADSC of cervix in Taiwan were associated with HPV infection. HPV 18 was predominant in ADC similar to the reports from most other regions. There was no correlation between HPV and histopathologic findings of ADC and ADSC. The punctate signals suggestive of viral DNA integration were found in all but one HPV positive cases. The result supports the hypothesis that HPV may play an important role in pathogenesis of cervical ADC and ADSC.

Effect of menstruation on serum CA125 levels.

CA125 levels were measured in the sera of 54 women with normal menstrual cycle and without infectious, benign and malignant gynecologic disorders. In 54 subjects studied, 13 (24%) had no significant variations in serum CA125 levels throughout the menstrual cycle. In contrast, there 41 (76%) had significant variations in serum CA125 with peak levels (51.8 +/- 6.5 U/ml, mean +/- SEM) during menstruation. The concentration reached a normal value (17.7 +/- 1.6 U/ml, mean +/- SEM) at proliferative phase, and remained low throughout the rest phases of the cycle. The mean peak level was significantly higher than that at proliferative phase (P < 0.001), where as no significant difference in mean concentration was detected between sequential phases from proliferative phase to premenstrual phase (P > 0.1). Among 41 with variable CA125 levels in the menstrual cycle, more than half of them, namely 39% of the total (21/54), had the levels of the upper limit or normal values.

Characterization of Cryptosporidium parvum in human and animal feces by single-tube nested polymerase chain reaction and restriction analysis.

A DNA isolation and purification method is described that produced DNA free of inhibitory substances in 148 of the 159 analyzed fecal samples. The polymerase chain reaction (PCR) product from a sensitive single-tube nested PCR that amplifies a part of an oocyst protein was used to characterize Cryptosporidium parvum genotypes by a simple restriction analysis. Genotype 1 was solely detected in human-derived oocysts, genotype 2 was present in both animal and human-derived oocysts. The ratio between both genotypes in humans in The Netherlands varied markedly between samples obtained during a period of augmented cases of cryptosporidiosis in the western part of the country and randomly selected samples from gastroenteritis patients. Sequence analysis of a 581-bp fragment from the nested PCR product revealed 12 nucleotide substitutions between the two genotypes. Sequences from isolates in each genotype group were identical.

An evaluation of chemotherapy in patients with cancer of the cervix and lymph node metastases.

During the past twelve years, out of the 288 cervical cancer patients who had lymph node involvement, the recurrence rate in the lymph node, was 26.6% if one or two nodes were involved and 50.8% if three or more nodes were involved (P < 0.0001). The recurrence rate of patients who received eight intravenous treatments (at monthly intervals) of multi-agent chemotherapy was lower than those who did not receive treatment. Of patients with one or two positive lymph nodes, 114 received treatment while 50 did not; their respective recurrence rates were 19.3% and 42.0%, a statistically significant difference (P < 0.025). Of patients with three or more positive lymph nodes, 97 received treatment and 27 did not, their respective recurrence rates, were 46% and 66% (P = 0.30) and the difference is not statistically significant. It would seem that multi-agent chemotherapy may reduce the recurrence rate in patients with cancer of the cervix and positive lymph nodes.

The outcome of the patients with recurrent cervical carcinoma in terms of lymph node metastasis and treatment.

Of the 908 patients who underwent radical hysterectomy and pelvic lymphadenectomy for invasive cervical cancer from 1973 to 1983, 139 (or 15.30%) had recurrences. The recurrent rate in the 175 patients with positive pelvic lymph nodes was 32.6%, compared with a 11.2% in the 733 patients with negative nodes (P less than 0.001). This suggests that cervical cancer patients with negative nodes acquire better prognosis after surgical treatments. Not only is recurrence much less frequent in patients with negative nodes, but also the outcome of treatments is significantly in favor of such patients: (A) 51 recurrent patients refused further treatments owing to personal reasons. None survived over 3 years; (B) The survival rate is far higher for treated patients formerly with negative nodes. Sixty of the 82 patients achieved a 5-year survival of 17.74% compared with a 2-year survival of 21.64% only in 28 patients with positive nodes. This suggests that our treatments on patients with recurrent cervical cancer are more effective when the patients have previously had negative nodes, and that refusal of treatment results in quick death.

[Hematometra in patients with cervical cancer--its CT presentation and clinical significance].

Cervical cancer is the most common gynecologic malignancy in Chinese. Clinical staging has been traditionally used in cervical cancer, according to international Federation of Gynecology and Obstetrics (FIGO) staging classification. Computed tomography was an adjunctive modality for detecting paraaortic lymph nodes in preoperative evaluation. But CT has failed to accurately define the extent of parametrial and vaginal invasion. Here, an attempt has been made to define indirect clues alerting to invasive cervical cancer. Hematometra can be seen in CT as a dilated uterine cavity with retention of significant fluid. The incidence of hematometra was 5% (5/101) in control group, and 26% (22/84) in cervical cancer. Hematometra cannot be more specific for cervical cancer, with an accuracy of 64%, sensitivity of 82% and specificity of 61%. Hematometra was found to have a statistically high relationship with high cancer staging and uterine invasion. The Chi-square values were 14.8 (P < 0.005) in high cancer staging, and 19.8 in uterine invasion. The accuracy of hematometra was 65% in high cancer staging, and 74% in uterine invasion. Hematometra was more common in postmenopause women, with accuracy elevated to 80% for uterine invasion. This is probably related to senile atrophy or endophytic growth of the cervix into the uterus as well as to hormone replacement. These were five false positive instances of hematometra, all unrelated to cervical cancer. They presented with marked fluid and a solid mass in the uterine cavity, and included endometrial adenocarcinoma, uterine myoma and leiomyosarcoma. None of cervical cancer showed a solid mass in a dilated uterine cavity.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical diagnosis in microinvasive carcinoma of the uterine cervix.

This retrospective study collected the surgical tissues and the clinical records of 197 surgically treated patients with microinvasive carcinoma of the cervix, which was defined as a limited microinvasion not more than 3 mm in depth regardless of lymph-vascular involvement. Depth of invasion was 1 mm or less in 13.2% and 1.1 to 3 mm in 86.8%. The mean age was 47.2 years. About half of the patients were asymptomatic but suspected cytologically. Random cervical biopsy alone was inadequate for diagnosis. Cone biopsy demonstrated an accuracy of 94% in diagnosis, but failed to eliminate microinvasive carcinoma in 23.0% of the hysterectomy specimens. In 14 cases, the invasion was more extensive in the uterus than in the cone. A positive correlation has been found between the diagnostic rate of conization and the depth of stromal invasion. Cervical conization, while relatively accurate in assessing the existence of stromal invasion that characterizes microinvasion, failed to diagnose those with deeper stromal invasion, especially beyond 1 mm. The recommended approach in diagnosing microinvasion is careful colposcope-directed cone biopsy and proper examination of the conization specimen in order to exclude the possibility of more advanced disease.

Chemosensitivity testing of an ovarian cancer cell line: comparison of MTT assay and [3H]-thymidine incorporation.

Chemosensitivity test has its role in cancer therapy. Using an accurate, efficient, and simple way to choose the proper chemosensitive drugs in our clinical study will help advance our work. The MTT assay is a rapid, precise, and new method to perform drug sensitivity assay. We used an ovarian cancer cell line (OC-3L-VGH) to compare the accuracy of the MTT and the [3H]-TdR incorporation assay in measuring chemosensitivity of 7 anticancer drugs. Good correlation was observed between the MTT and the [3H]-TdR assay for drug sensitivity testing (r = 0.893, P less than 0.001). Based on this study we found it may be preferable to use the MTT assay for chemosensitivity screening.

Simultaneous endometrioid carcinoma of the uterine corpus and ovary.

The carcinoma with simultaneous involvement of the endometrium and the ovary is an uncommon but well recognized event. The determination of clinical stage depends on which of the two sites is considered to be the primary. Combined involvement may occasionally represent independent primary neoplasm. A review of all cases with a tissue diagnosis of endometrioid ovarian carcinoma and concomitant endometrial carcinoma was undertaken to identify those cases which possibly had independent primaries. Three such cases with disease confined to the pelvis were identified on the basis of pathologic features. The incidence of endometrial carcinoma in patients with endometrioid ovarian carcinoma was 15.8% (3/19). They were treated surgically with adjuvant therapy. Two patients died of disseminated carcinoma 1 and 4 years later respectively. The only one patient alive had been free of disease for 25 months after initial therapy. These endometrioid neoplasms simultaneously occurring in ovary and endometrium are considered to be primary tumors. The morphologic reasons for this view are discussed.

Leiomyosarcoma of uterus: a review of 14 cases.

A detailed clinicopathologic study of 14 patients with leiomyosarcoms of the uterus was made. Twelve of 14 patients were followed up for 2 or more years. The median age was 49, the youngest patient was 20, and the oldest was 68. The predominant symptoms were abnormal vaginal bleeding and abdominal pain. The preoperative dilation and curettage established the correct diagnosis was 2 of 6 patients (33%). The predominant method of treatment was total abdominal hysterectomy (TAH). Five patients had adjuvant chemotherapy, 4 had adjuvant radiotherapy, 2 patients had chemotherapy and radiotherapy for adjuvant treatment, and one had adjuvant hormonal therapy. The overall cumulative probability of survival rate at 5 years was 29.6%. The mitotic count, margin type, tumor size, and the presence of necrosis did not affect the prognosis. Favorable prognostic features are low pleomorphism, lower staging, and aggressive management.

Effect of preoperative transdermal ketoprofen on post-hysterectomy pain.

BACKGROUND: In an attempt to reduce central sensitization after tissue injury, the concept of "pre-emptive analgesia" was evolved. The aim of the present study was to evaluate the analgesic effect of pre-incisional transdermal ketoprofen on post-hysterectomy pain. METHODS: Sixty patients scheduled for elective trans-abdominal total hysterectomy were divided into three groups. The day before surgery, patients in Group 1 received transdermal ketoprofen 30 mg over the proposed surgical area twice; patients in Group 2 received a placebo patch under a similar design; patients in Group 3 received transdermal ketoprofen 30 mg over right thigh twice. Operations were performed under general anesthesia. Postoperatively, patients received patient-controlled analgesia with morphine for pain relief, and pain was assessed by visual analogue pain scale (VAS). Hemodynamic parameters, respiratory rate, sedation scale, morphine consumption and associated side effects were also recorded. RESULTS: There was no significant difference among groups with respect to VAS, sedation scale, blood pressure, respiratory rate or morphine consumption within 24 hours postoperatively. The mean time for first morphine demand was significantly delayed in Group 1 patients (p < 0.05). The incidence of nausea and vomiting among the three groups showed no significant difference. CONCLUSIONS: It seems that pre-incisional transdermal ketoprofen (30 mg, twice the day before surgery) has only a limited pre-emptive effect on post-hysterectomy pain as indicated by delayed first morphine request. Further, it had no effect on postoperative VAS, morphine consumption or incidence of nausea and vomiting.

Computed tomography in the diagnosis of organic bowel obstruction.

BACKGROUND: This study examined the usefulness of computed tomography (CT) scan for cases of organic intestinal obstruction, with two simple criteria. METHODS: One hundred and thirteen patients with clinical suspicion of bowel obstruction were referred for CT scans. A line was drawn between the dilated proximal, and the collapsed distal bowels. A careful search was conducted on this line for obstructive lesions. The results were reported to be organic obstruction if there was an abrupt change of caliber (Criterion I) or a soft tissue mass around the dilated bowel (Criterion II). The judgement based on the CT findings. RESULTS: Eighty-eight cases proved to have bowel obstruction. With Criterion I, the sensitivity was 59.1%, and specificity, 88% with Criterion II, the sensitivity was 56.3% and specificity 100%. If either of them was considered to be a positive sign of organic obstruction, the sensitivity was 100%, the specificity 88% and the accuracy 97.3%. The nature of the obstructions were precisely predicted in 76 patients (86%). CONCLUSIONS: With these two simple criteria, CT scan can achieve high accuracy and is a recommendation in virtually every instance when intestinal obstruction is suspected.

Adenosquamous cell carcinoma of the cervix--a clinical analysis of 23 cases.

From January 1976 through December 1985, 895 patients with cervical carcinoma were treated with radical hysterectomy and pelvic lymphadenectomy. The surgical specimens of 23 cases were proved to be adenosquamous cell carcinoma, the incidence being 2.6%. Among them, 15 were at stage IB, 7 were at stage IIA and one was at stage IIB. The overall 5-year survival rate was 55.0% and there was no difference between patients at stage IB and IIA. During the same period the 5-year survival rate of squamous cell carcinoma was 87.5% for patients at stage IB and 75.0% for patients at stage IIA. Pelvic lymph node metastasis and parametrial involvement are considered to be poor prognostic factors. When metastasis or invasion happens, the metastatic or invasive lesions can be found in the form of pure squamous carcinoma or adenocarcinoma. Postoperative adjuvant radiotherapy (external irradiation plus brachytherapy) seems to be effective in preventing recurrence. Chemotherapy (PVB regimen) needs more clinical evaluation. In this study, when metastasis or recurrence developed, the response to radiotherapy and/or chemotherapy were poor and 75% of patients died within one year.