Carcinoma of the endometrium: Mayo clinic experience.

Five hundred and twenty-three patients with endometrial carcinoma treated at the Mayo Clinic from 1952 through 1962 have been followed up for a minimum of 10 years. These patients have been assigned International Federation of Gynecology and Obstetrics classifications retrospectively; 324 were stage IA and 85 were stage IB. Only 24 patients were stage II and 90 were stages III and IV, combined. Most patients were symptomatic, and a significantly greater number of stage IV patients had symptoms for a longer duration. The average age was 59 years; most patients were postmenopausal and there was a high degree of nulliparity. Seventeen and one-half percent of all patients in this series had a second carcinoma at some time, with breast and colon being the most common second primaries. Treatment was basically total hysterectomy and bilateral salpingooophorectomy with postoperative radiation added on an individualized basis. Seventy-four percent of the 523 patients survived 5 years and 64% survived 10 years. This varied from a 90% 5-year survival in 249 patients with stage IA or IB, G1, to a 13% 5-year survival in 46 patients with stage IV lesions.

A randomized controlled trial of a computer-based physician workstation in an outpatient setting: implementation barriers to outcome evaluation.

OBJECTIVE: A research prototype Physician Workstation (PWS) incorporating a graphical user interface and a drug ordering module was compared with the existing hospital information system in an academic Veterans Administration General Medical Clinic. Physicians in the intervention group received recommendations for drug substitutions to reduce costs and were alerted to potential drug interactions. The objective was to evaluate the effect of the PWS on user satisfaction, on health-related outcomes, and on costs. DESIGN: A one-year, two-period, randomized controlled trial with 37 subjects. MEASUREMENTS: Differences in the reliance on noncomputer sources of information, in user satisfaction, in the cost of prescribed medications, and in the rate of clinically relevant drug interactions were assessed. RESULTS: The study subjects logged onto the workstation an average of 6.53 times per provider and used it to generate 2.8% of prescriptions during the intervention period. On a five-point scale (5 = very satisfied, 1 = very dissatisfied), user satisfaction declined in the PWS group (3.44 to 2.98 p = 0.008), and increased in the control group (3.23 to 3.72, p < 0.0001). CONCLUSION: The intervention physicians did not use the PWS frequently enough to influence information-seeking behavior, health outcomes, or cost. The study design did not determine whether the poor usage resulted from satisfaction with the control system, problems using the PWS intervention, or the functions provided by the PWS intervention. Evaluative studies should include provisions to improve the chance of successful implementation as well as to yield maximum information if a negative study occurs.

Endometrial cancer associated with feminizing ovarian tumor and polycystic ovarian disease.

Feminizing ovarian tumors and polycystic ovarian disease may cause endometrial cancer by abnormal, unopposed endogenous estrogenic stimulation. We reviewed the clinical course of 72 endometrial cancer patients with a concomitant feminizing ovarian tumor or polycystic ovarian disease and compared tumor characteristics and treatment results with those exhibited by 523 patients treated for endometrial cancer alone. With functioning ovarian tumor and with polycystic ovaries, the cancer tended to be more often low-grade, low-stage, and superficial than did endometrial cancer alone. The high 5-year and 10-year survival rates observed in our functioning ovarian tumor-polycystic ovary patients support the conclusion that endometrial carcinoma with a coexistent endogenous estrogenic stimulus has a more favorable prognosis (P less than 0.01) than endometrial carcinoma alone.

Fine needle aspiration of para-aortic and pelvic lymph nodes showing lymphangiographic abnormalities.

Fifty-six fine needle aspirations of lymphangiographically abnormal pelvic and para-aortic lymph nodes were performed in 50 patients at The University of Michigan between January 1, 1977, and May 31, 1980. Fine needle aspiration was used both in the initial evaluation of patients with gynecologic malignancies and in the investigation of persistent and recurrent malignant disease. The overall diagnostic accuracy of fine needle aspiration was 74.0%. Fine needle aspiration yielded diagnostic cytologic specimens; it was safe and well tolerated, and in some instances it permitted the diagnosis of lymph node metastasis without laparotomy.

Modern management of gestational trophoblastic disease.

Gestational trophoblastic disease is a disorder of pregnancy which may present in a very benign or malignant fashion. Hydatidiform mole complicates approximately 1 in 2000 pregnancies in the United States. The diagnosis may be made prior to evacuation if the signs and symptoms are kept in mind. When the patient presents with spontaneous expulsion of typical molar tissue, a complete evaluation is carried out, including physical examination, uterine curettage for histologic study, and initiation of weekly beta subunit of HCG determinations. At 8 weeks' post-evacuation, about 50% of patients continue to have detectable serum HCG levels. Of these patients, about half may develop chorioadenoma destruens (invasive mole) or choriocarcinoma and require chemotherapy (6, 16). Patient stratification in a clinical classification system based on anatomical extent of disease and certain risk factors is essential for proper management. Review of results obtained at gestational trophoblastic disease treatment centers has shown that with exception of the high-risk patient, virtually 100 per cent cure is possible with early diagnosis and appropriate treatment. Treatment of the high-risk patient with initial triple-drug chemotherapy and simultaneous irradiation of liver or brain metastases may be expected to yield a 90 per cent complete remission. If complete remission in the high-risk patient is maintained for 3 months after cessation of treatment, there appears to be a 98 per cent chance of remaining free of disease (47). The information accumulated in the 25 years since methotrexate was introduced into the treatment of gestational trophoblastic disease has made these excellent results possible. Aggressive multiagent chemotherapy, proper patient classification, radiation, surgery, and utilization of the beta subunit of HCG to monitor therapy are all pivotal in achieving these successes of modern management.

Role of needle biopsy in the investigation of gynecologic malignancy.

Three methods were used to investigate and evaluate patients with primary and persistent/recurrent pelvic malignancy in the gynecologic oncology services at two medical centers. The 22-gauge Chiba needle was utilized with fluoroscopic guidance to perform fine needle aspiration (FNA) of pelvic and paraaortic lymph nodes that appeared abnormal on lymphangiography (LAG). The Tru-cut needle was used to obtain tissue samples from beneath the surface epithelium of the cervix, vaginal vault and parametrium. A disposable, hand-held syringe and 20-gauge needle were used to aspirate supraclavicular and inguinal lymph nodes and cul-de-sac nodules. One hundred thirty-eight patients were evaluated, with positive results in 66 (47.8%). Surgical exploration was used to further investigate 16 negative results that did not correlate with LAG and/or clinical presentation. The sensitivity and predictive value of a negative result for the three methods was Chiba needle FNA/LAG, 62.1% and 65.6%; Tru-cut needle biopsy, 94.4% and 93.5%; and hand-held syringe and needle, 87.5% and 66.7%, respectively. All three techniques proved to be safe, uncomplicated and rapid methods of assessing gynecologic tumor spread. Positive results from these techniques can often replace surgical exploration, with a considerable savings in patient morbidity and hospitalization, and permit additional treatment to proceed without delay. Negative results still require surgical validation.

A validity study of the WAIT in closed head injury.

This investigation is a validity study on an instrument designed to assess the cognitive status of CHI patients in the acute phase. The Wolinsky Amnesia Information Test (WAIT) is a questionnaire, orally administered and then scored in a standardized format. Interrater reliability has been previously demonstrated. In this study, the WAIT was compared to the Galveston Orientation and Amnesia Test (GOAT), CT scans, and the Glasgow Coma Scale (GCS). Seventy-five subjects participated in the study, all hospital trauma patients at an urban regional trauma centre, who had been referred to the neuropsychology consult service for cognitive testing. Patients were screened to rule out preexisting developmental, drug, alcohol, or documented prior LOC history. Patients' ages ranged from 18-59, with a mean of 33.45 years. A large majority of the patients (81.3%) were diagnosed with a mild level of CHI. Concurrent, discriminative, and construct validity of the WAIT were investigated, and found satisfactory. The data were submitted to factor analysis in order to uncover underlying constructs. In addition to the 'orientation' and 'amnesia' factors identified through factor analysis, a third factor was found and labelled: 'personal temporal/continuum memory'. Limitations of the study and possible directions for future research are discussed.

Clear cell ("mesonephroid") adenocarcinoma of the vulva arising in endometriosis: a case report.

A very unusual case of an apparent primary clear cell adenocarcinoma of the vulva in a 57-year-old female is presented. The carcinoma arose in an area of endometriosis within the canal of Nuck in the superior aspect of the right labium majus. Smooth muscle fibers presumably representing remnants of the extrapelvic round ligament were found associated with the endometriosis. Of interest is the fact that the patient underwent right herniorrhaphy 9 years earlier. Although several cases of primary adenocarcinoma arising within the vulva have been reported, none has arisen in areas of endometriosis within the canal of Nuck. No case in the literature of a primary clear cell adenocarcinoma arising from endometriosis in the canal of Nuck and in association with the extrapelvic portion of the round ligament could be found.

A meta-analytic evaluation of the polymerase chain reaction for the diagnosis of HIV infection in infants.

OBJECTIVE: To evaluate the sensitivity and specificity of the polymerase chain reaction (PCR) for the diagnosis of infection with human immunodeficiency virus (HIV) in infants. DATA SOURCES: We used studies published between 1988 and 1994 identified in a literature search of 17 databases, including MEDLINE. STUDY SELECTION: Studies were included if DNA amplification by PCR was performed on peripheral blood mononuclear cells from infants or children. DATA EXTRACTION: Two investigators independently extracted data. The study design was assessed independently by 2 investigators who were blinded to study results. DATA SYNTHESIS: Thirty-two studies met the inclusion criteria and were analyzed. The median reported sensitivity was 91.6% (range, 31%-100%), and the median specificity was 100% (range, 50%-100%). A summary receiver operating characteristic curve based on all 32 studies indicated that PCR has a maximum joint sensitivity and specificity between 93.2% and 94.9%. Subgroup analysis indicated that the joint sensitivity and specificity was significantly (P = .04) higher in older infants (98.2%) than in neonates (aged < or = 30 days; 93.3%). For infants at low risk of perinatal transmission (probability of transmission, 8.3%), the positive predictive value for PCR is 55.8% in neonates and 83.2% in older infants. A negative PCR result reduces the probability of HIV infection to less than 3%. No studies met all criteria for study design. CONCLUSIONS: Although PCR is one of the best available tests for diagnosis of HIV infection in neonates and infants, it is not definitive. Therefore, PCR should be interpreted with the aid of careful clinical follow-up examinations. The sensitivity and specificity of PCR in neonates is lower than in older infants, which results in a low positive predictive value; however, negative tests are informative. Delaying the use of PCR until after the neonatal period or repeating PCR on independent samples obtained 30 to 60 days later will reduce test errors.

Impact of cervical intraepithelial neoplasia diagnosis and treatment on self-esteem and body image.

Most women commonly take an abnormal Pap smear to be indicative of invasive cancer. This fear can permeate their lifestyle to the degree that it may influence receptivity to medical procedures as well as promote cervical intraepithelial neoplasia (CIN) to invasive squamous cell carcinoma of the cervix. This longitudinal study was undertaken to provide baseline data on self-esteem and body image as the patient progresses from the initial visit through the postsurgery visit. Twenty patients ranging in age from 15 to 40 years were followed through diagnosis and treatment with colposcopic biopsy showing 25% CIN I, 45% CIN II, and 30% CIN III. Concern for cancer overrode all other concerns except during the postsurgery visit, at which time loss of attractiveness was paramount. Loss of sexual functioning ranked high in all visits. Self-esteem was lowest and anxiety highest during the initial and postsurgery visits. Positive body image was greatest when the results of the biopsy were received and during the postsurgery visit. Patients and sexual partners exhibited similar patterns of anxiety about the medical condition. Psychological repercussions from CIN occurred even prior to diagnosis.

Assessment of primary and metastatic ovarian cancer by positron emission tomography (PET) using 2-[18F]deoxyglucose (2-[18F]FDG).

The potential of positron emission tomography (PET) to distinguish benign from malignant ovarian tissue was evaluated by comparing the results of F-18 fluoro-2-D-deoxyglucose (F-18-FDG) PET scans with computed tomography and surgical findings. If sufficiently sensitive, this method might play a role in localizing metabolically active tumor sites for diagnosis, staging, and follow-up of ovarian cancer. Fifty-one patients had imaging studies prior to laparotomy for suspected ovarian cancer. PET scans were done with an ECAT 931-08-12 or ECAT EXACT (Model 921, Siemens/CTI, Knoxville, TN) after iv injection of 185-370 MBq of F-18-FDG. (ECAT is a trade name for "emission computerized axial tomograph.") Data were acquired in dynamic scanning mode and time activity curves (TACs) were evaluated in multiple regions of interest identified by visual interpretation of the PET scans. Scan interpretation, standardized uptake values, and TAC profiles were related to surgical and histological findings. The results of this pilot study show good correlation between PET and histological findings. The positive predictive value of PET for ovarian cancer was 86% and, perhaps more important, the negative predictive value was 76%. This early work indicates that PET may be useful in the management of patients with ovarian neoplasms by identifying occult foci of metabolically active tumor that do not appear on morphological studies.

Flow cytometry as a prognostic indicator in women with borderline epithelial ovarian tumors.

Flow cytometry has been used to rapidly and reliably measure DNA content in malignant tumor cells. Although several studies have suggested that DNA ploidy is a powerful predictor of survival in women with epithelial ovarian cancer, few have determined the usefulness of this procedure in women with borderline tumors. Using data from a population-based tumor registry covering all of western Washington State, women who died prior to 1992 as a consequence of developing a borderline ovarian tumor between 1975 and 1986 were compared to an age, histology, and histologic stage-matched sample of women with the same diagnosis still living after at least 5 years of follow-up. Flow cytometry analysis was conducted using sections of tumor from the original paraffin blocks. Overall, 25% of the women who died and 24% of those still alive had aneuploid DNA tumors (odds ratio = 1.2, 95% CI = 0.3-4.9). This lack of association stands in contrast to the strong relationship of aneuploid status to mortality in an earlier, similarly designed, study of borderline ovarian tumors. We believe that additional studies are required prior to concluding that the clinical course of women with borderline tumors can be predicted by the ploidy status of their tumor's DNA.

Exogenous estrogen and endometrial carcinoma: case-control and incidence study.

Recent independent case-control studies have indicated that treatment with exogenous estrogen is associated with an increase in the risk of endometrial cancer. This question was studied in Olmsted County, Minnesota, by identifying all cases of endometrial cancer among residents over a 30 year period (1945 through 1974) and by matching four controls to each of the 145 patients. The rate of past exposure to any exogenous estrogen for any duration was about the same for patients as for controls. However, the estimated relative risk of endometrial cancer associated with conjugated estrogen treatment of 6 months or longer was 4.9 (P less than 0.01), and this increased to 7.9 (P less than 0.01) with exposure for 3 years or longer. The risk increased with larger doses (1.25 mg. or more) and continuous administration of conjugated estrogens. The incidence of endometrial carcinoma over the three decades of the study, corrected for an increasing rate of hysterectomy, was constant. Thus to this time, the low rate of use of conjugated estrogens in this region over the past 30 years apparently has not had an appreciable impact on the incidence of endometrial cancer.

PIP: A relationship between exposure to exogenous estrogens and endometrial carcinoma has been reported in numerous studies. The incidence among those so exposed has been estimated to have been increased from 7.5 to 8 times that of those not exposed. Long-term therapy with estrogens for menopausal symptoms has been the usual history. Breast cancer patients treated with estrogens and young women taking sequential oral contraceptives have had increased risks. In this study, the records of Olmsted County, Minnesota, residents with endometrial uterine cancer diagnosed between 1945-1974 at the Mayo Clinic or at other medical facilities were reviewed. There were 122 adenocarcinomas and 23 adenoacanthomas. In 3 instances, adenocarcinomas contained zones of uterine sarcoma. For each of the 146 patients there were 4 age-matched controls. Estrogen use for 6 months or more was recorded for 39 (27%) of the 145 cases and for 163 (28%) of the 580 controls. The controls had more frequent histories of short-term estrogen therapy. Cancer patients had relatively more estrogen use for menopausal symptoms. The relative risk of endometrial cancer tended to increase with the duration of exposure to conjugated estrogens from 2.0 with any exposure to 4.9 (p less than .01) after 6 months or more and to 7.9 after 3 years or more. The risk increased with larger doses (1.25 mg or more) and with continuous administration of conjugated estrogen. Myometrial invasion was superficial in 77 cases and deep in 44 cases. Long-term use of conjugated estrogen was frequently associated with low-stage low-grade superficially invasive endometrial malignancy. The 5-year survival rate of the 145 patients was 85%. Patients with Stage 1 had a 95% relative 5-year survival rate. Those with Stages 2, 3, or 4 had 50% survival rates. Of other risk factors, obesity and nulliparity were noted. Patients had more frequent records of benign cystic adenoma and of adenomatous hyperplasia than controls. The corrected age-specific rate for endometiral cancer increased to a maximum of about 90/100,000 population per year in the group aged 55-64 and then diminished with age. An increase in endometrial cancer among those at risk may have been nullified by an increase in those who have had a hysterectomy. In this study the incidence of endometrial carcinoma in Olmsted County does not show an increase in the last 3 decades. It is noted that the long-term use of conjugated estrogens in this area has been relatively low.