Listeria monocytogenes chorioamnionitis: diagnosis by transabdominal amniocentesis.

Two cases of Listeria monocytogenes chorioamnionitis are presented in which transabdominal amniocentesis was used to confirm the diagnosis and to obtain reliable intrauterine culture material free from lower genital tract contamination. The mechanisms of infection with Listeria monocytogenes in the pregnant patient are discussed.

Reticuloendothelial neoplasia of the female genital tract.

Twelve patients thought to have gynecologic tumors subsequently were found to have lymphoma or leukemia. Eleven tumors involved the genital organs; one involved the retroperitoneal pelvic lymph nodes. A lymphoma originated in the genital tract in 7 patients, and secondary involvement occurred in 2 patients. One patient with a previously treated lymphoma and 1 with leukemia in remission developed ovarian tumors as the first sign of relapse. The difficulty in diagnosis, need for appropriate treatment, and prognostic importance of the genital organs affected are discussed.

Management of vulvar intraepithelial neoplasia by carbon dioxide laser.

Thirty-three patients with vulvar intraepithelial neoplasia were treated with the carbon dioxide (CO2) laser. In 31 of these patients the lesion was completely eradicated by the laser treatment. All patients experienced moderate pain following the procedure, and 2 had severe pain. The only other complications were 1 case of bleeding and 1 of infection. The CO2 laser appears to be an acceptable treatment modality for vulvar cancer precursors provided patients are carefully evaluated prior to treatment and invasive carcinoma is ruled out.

Survival after extraperitoneal pelvic and paraaortic lymphadenectomy and radiation therapy in cervical carcinoma.

Clinical staging, bipedal lymphangiography, and extraperitoneal pelvic and paraaortic lymphadenectomy were performed in 95 patients with invasive squamous carcinoma of the cervix. Radiation therapy was modified on the basis of findings at operative staging. Patients have been followed from 16 to 91 months, with a mean of 41 months. The accuracy of clinical staging and the relative abilities of lymphangiography and lymphadenectomy to assess the retroperitoneal lymph nodes have been determined. Five-year survival with respect to stage of disease and status of the pelvic and paraaortic lymph nodes was calculated by the life-table method. Seventy-five percent of patients with no lymph node metastases are projected to be alive at 5 years without recurrence. Fifty-six percent with pelvic lymph node metastases and 23% of those with paraaortic lymph node involvement are projected to be free of disease at 5 years. The risk of lymph node metastases increases with either the stage of disease or the volume of the primary tumor independently of stage. The presence of lymph node metastases adversely affects survival regardless of the stage of the primary tumor. Clinical staging as accepted by FIGO is inadequate in that it ignores patients with pelvic or paraaortic lymph node metastases. The accuracy of detection in the individual patient does not increase with the addition of lymphangiography. Operative staging can be performed safely by the extraperitoneal route and radiation therapy can be modified on the basis of the true extent of disease. Radiation therapy fails to cure patients because of distant dissemination of disease as well as an inability of conventional radiotherapeutic techniques to sterilize a large primary tumor volume.

Intraoperative radiation in the treatment of advanced cervical cancer.

Nineteen patients with invasive cervical cancer were treated with intraoperative radiation and most of the patients subsequently received conventional external radiation therapy and intracavitary applications. The technique, resulting complications, and survival of the patients are discussed.

Nd: YAG laser therapy of rectosigmoid bleeding due to radiation injury.

The Nd:YAG laser was used to treat a patient bleeding from the rectosigmoid as a result of radiation injury related to therapy for cervical carcinoma. Successful laser therapy was performed after a diverting colostomy failed to control persistent bleeding. Further surgical procedures were not required. Characteristics of Nd:YAG laser as compared with those of the carbon dioxide and argon lasers are considered.

Ovarian carcinoma. The significance of restaging laparotomies with negative outcomes.

The role of restaging laparotomy in the treatment of ovarian carcinoma is currently being reevaluated. This study was initiated to examine the predictive value of a negative outcome. Between November 1974 and October 1983, sixty-three patients with no clinical evidence of disease underwent 70 restaging laparotomies for ovarian carcinoma. The findings of 34 (49%) of these procedures were negative for residual disease. Patient follow-up ranged from 30 to 137 months. Twenty-eight patients are alive with no evidence of disease with a median follow-up of 62 months. Four patients have died of a second primary tumor. Only two patients had recurrence of their ovarian carcinoma following restaging laparotomy with negative findings (recurrence rate, 5.9%; 13.3% for patients with advanced disease). Patients with negative findings at restaging laparotomy have an excellent prognosis and a good chance of being cured of their disease.

Measure of blood flow by the multiple radioactive microsphere technique in radiated gastrointestinal tissue.

In this study, two different radioactive microspheres were used to measure blood flow of an irradiated segment of small intestine in four dogs before, and 12 days after, irradiation with 2000 rad. The technique and implications are discussed. Using multiple radioactive microspheres, the study demonstrated an increased blood flow in irradiated tissues twelve days after a single dose of 2000 rad. There was also an increase in blood flow to adjoining nonradiated segments of intestine in the same animal. These observations may be of significance in clinical applications of radiation therapy and surgery. A major surgical concern is the impaired healing of irradiated tissue in the immediate postradiation period. The mechanism of this has generally implicated decreases in the perfusion of irradiated tissue. No decrease in blood flow was shown in this study, suggesting that other mechanisms, e.g., stem cell depletion, should be considered. Further studies of this type are recommended to increase understanding of the blood flow in irradiated tissue.

Obstetrics and gynecology: considerations in career selection.

Current training programs in obstetrics and gynecology are not producing an excess of specialists in view of future manpower needs. In addition to being specialists and consultants, obstetrician-gynecologists also function as providers of primary care for women. During the last decade, three formal sub-specialties of obstetrics and gynecology have evolved: gynecologic oncology, maternal-fetal medicine and reproductive endocrinology. These have improved patient care and have altered the structure of resident education. With more American medical school graduates entering this specialty, the quality of resident applicants has improved, creating intense competition for desirable training positions. Those inclined toward a career in obstetrics and gynecology can be assured that it will provide an increasingly favorable and challenging environment for professional activity in the future.

Alterations in biosynthesis of progesterone in human corpora lutea of pregnancy by prostaglandins.

PIP: This study concerns the effect of prostaglandins F2alpha (PGF2alpha) and E1 (PGE1) on the biosynthesis of progesterone in human corpora lutea of midpregnancy. The corpora lutea were obtained at the time of laparotomy for termination of gestation between 14-18 weeks. Extraction and isolation of progesterone was carried out according to traditional techniques. The addition of PGF2alpha appears to slightly decrease the progesterone content of the corpus lutea of pregnancy. Additions of PGE1 to the corpora lutea incubations resulted in no significant differences in either the progesterone content or the incorporation of sodium acetate into progesterone. These results support the contention that PGF2 alpha is luteolytic in the corpus luteum of gestation. The lack of change in peripheral progesterone values following infusion with PGF2alpha may be related to a time factor. In addition, there is an increase in the peripheral plasma level of PGF2alpha in the luteal phase of the menstruation cycle. However, the secretion of this compound results in inhibition of the de novo biosynthesis of progesterone in the corpus luteum.^ieng

An alternative approach to the vertical midline abdominal incision for staging in ovarian carcinoma.

The case report describes a situation that required staging laparotomy for ovarian cancer but the patient refused vertical incision for cosmetic reasons. The technique employed a low transverse skin incision with development of a skin flap and horizontal transection of the midabdominal wall near the level of the umbilicus. Operative exposure was adequate for standard staging procedures and the cosmetic requirements of the patient were satisfied.

Stage III epithelial ovarian cancer: the role of maximal surgical reduction.

One hundred forty-two cases of ovarian cancer of epithelial origin treated at Georgetown University Hospital between 1974 and 1980 were analyzed. Seventy-five patients (52.8%) were found to have Stage III disease at the time of the initial laparotomy, and the purpose of this study was to assess the outcome of the management in this group of patients. In spite of an aggressive approach, complete tumor excision could only be affected in 13 of the 75 Stage III cases (17.3%). Residual disease of less than 2 cm was achieved in a further 8 cases (10.7%). The ability to perform complete tumor clearance bore no relationship to the grade of the tumor. The survival rate in the complete clearance group was 100% with a mean survival time of 45 months (range 10-90 months) and 10 of these patients have been shown to be free of disease by second-look laparotomy. The outcome in terms of survival and disease-free status in these two groups of patients was unaffected by various chemotherapy regimens and the only factor of importance appeared to be the success of the initial surgery in clearing the disease.

Single-dose actinomycin-D treatment for nonmetastatic gestational trophoblastic disease. A prospective phase II trial of the Gynecologic Oncology Group.

The Gynecologic Oncology Group (GOG) conducted a prospective trial of single-dose Actinomycin-D (ACT-D) given intravenously (IV) at 1.25 mg/m2 every 2 weeks to patients with nonmetastatic gestational trophoblastic disease (NMGTD) in order to determine the efficacy of pulse scheduling and the frequency and severity of associated toxicity. Of 31 evaluable patients, 29 (94%) achieved remission after receiving a median of four courses of therapy. Two patients who failed to respond to pulse therapy were subsequently cured by alternative treatment. There were 93 toxic events in 133 cycles of therapy. Ninety-two percent of adverse effects were graded as mild or moderate, and 8% were graded as severe. No life-threatening toxicity occurred. Although single-dose ACT-D efficacy and toxicity is comparable to conventional therapy for NMGTD, the advantages of easier administration, greater patient convenience, and improved cost-effectiveness make it superior to other alternatives. On this basis it is recommended as the treatment of choice for NMGTD.

Intestinal operations in patients with ovarian carcinoma.

Forty-two patients with epithelial ovarian carcinoma underwent intestinal operations at the University of California, Los Angeles, and the City of Hope National Medical Center during the course of the disease. The patients were divided into three groups for purposes of this analysis. The first group had intestinal surgery during their initial laparotomy. Patients in the second group underwent intestinal operation at the time of re-exploration for recurrent disease but had no preoperative signs or symptoms of intestinal tract dysfunction, while those in the third group underwent re-exploration for symptomatic intestinal involvement by tumor. Operative complications, postoperative morbidity, and effect of the resection on disease outcome are analyzed for each group in an attempt to define the indications for intestinal resection or bypass in patients with epithelial ovarian cancer.

Vaginal intraepithelial neoplasia: Biologic aspects and treatment with topical 5-fluorouracil and the carbon dioxide laser.

A review of 41 evaluable patients was made in order to study vaginal intraepithelial neoplasia (VAIN) and to investigate new methods of treatment. Colposcopic examination of the vagina revealed white epithelium alone in 20 patients and white epithelium associated with vascular punctation in 15. No lesion had a vascular mosaic pattern. Most patients had multifocal disease located in the vaginal apex. Iodine staining was positive in six patients with negative colposcopic examinations. Twenty-four patients had severe dysplasia or carcinoma in situ, and 17 had minimal or moderate dyplasia. Associated genital disease occurred in 17 patients with antecedent cervical or vulvar squamous neoplasia, and six additional patients had coexistent lesions. The chronology of vaginal disease that appeared after treatment of cervical neoplasia suggests a persistent but decreasing likelihood of the development of VAIN with the passage of time. In patients followed without therapy, six had spontaneous remission of disease. Treatment was successful in 12 of 15 patients with topical 5-fluorouracil and in nine of 10 patients with the carbon dioxide laser. The advantage of these methods of treatment for patients with VAIN relative to surgical procedures and radiation therapy are considered.

Intraperitoneal chemotherapy complicated by erosion of a Tenckhoff catheter into the colon.

Insertion and maintenance of intraperitoneal catheters must be done with meticulous attention to detail. We recommend insertion under direct vision to minimize the incidence of intestinal perforation during catheter placement. Intraperitoneal catheters should not be placed in close proximity to a fresh intestinal anastomosis because this position may promote anastomotic dehiscence. Communication between the catheter and the intestinal lumen necessitates catheter removal.

The metabolism of cis-dichlorodiammineplatinum (II): distribution, clearance, and toxicity.

The distribution and toxicity of 195mPt-labeled cis-platinum were studied in two groups of dogs. Serum and tissue levels, renal and marrow toxicities, and urinary excretion were compared in dogs given cis-platinum, 3 mg/kg, intravenously with a group treated by intraperitoneal administration. Peak serum levels occurred immediately after intravenous administration and 8 hours after intraperitoneal instillation, at which time the two were identical and declined at similar rates. Mean levels of cis-platinum measured in peritoneal tissues on day 4 were higher in the intraperitoneal group. Blood urea nitrogen, creatinine, and white blood cell and platelet counts were similar in both groups. Bloody ascites and adhesion formation occurred in 37.5% of dogs treated by intraperitoneal administration. The intraperitoneal route of chemotherapy administration results in higher drug levels in target peritoneal tissues without a corresponding increase in systemic toxicity.

Comparison of the iv and ip routes of administration of cisplatin in dogs.

Cisplatin at a dose of 3 mg/kg was administered to dogs either iv or ip. Cisplatin concentrations in serum, urine, and tissues were measured with a radioisotope tracer method employing 195mPt cisplatin. Systemic toxicity was monitored by serial BUN, creatinine, and wbc and platelet counts. The mode of administration did not affect systemic toxicity since the changes in renal and bone marrow functions were identical in the two groups. Serum cisplatin levels following iv administration peaked at 13.5 micrograms/ml at 5 minutes and were biphasic with rapid initial decline and a prolonged elimination phase. In contrast, levels following ip administration increased rapidly to 1.5 micrograms/ml at 4 hours and then decreased with the iv levels. The amount of drug recovered in the urine was similar regardless of method of administration, with approximately 50% of the injected dose excreted by Day 4. The drug levels within the tissues on Days 4 and 8 were similar, with the exception of the tissues lining the peritoneal cavity. On Day 4 the tissues lining the peritoneal cavity had 2.5-8 times higher levels of drug after ip administration, and this difference was statistically significant (P less than 0.01). Local toxic effects encountered with ip administration consisted of bloody ascites on Day 4 (four of none dogs) and filmy adhesions on Day 8 (one of four dogs). It is concluded that ip cisplatin chemotherapy may increase the therapeutic index for small tumors which are confined to the peritoneal cavity.

Adenocarcinoma of the uterine cervix.

One hundred patients with primary adenocarcinoma of the uterine cervix were evaluated. Of the 48 Stage I patients, 13 were treated with radical surgery, 16 with radiation alone, and 19 with combination therapy. Life table analysis of Stage I patients showed no significant difference in survival for those treated with radical surgery or combination therapy. Both groups had a greater five-year survival (P less than 0.05) than those treated with radiation. Recurrences in Stage I were more frequent with primary radiation alone, both locally and at distant sites (P less than 0.01). Greater tumor size was related to poorer survival, and failures in patients with larger lesions were more common in those treated with radiation therapy. Survival for the 32 Stage II patients was greater for those treated with combination therapy. Higher tumor grade was associated with poorer survival for each stage, regardless of treatment. More complications were associated with radiation therapy than with radical surgery. Radiation therapy alone is not sufficient for patients with Stage I and II disease, and radical surgery may be appropriate treatment for Stage I disease.

Possible prognostic significance of human papillomavirus type in cervical cancer.

While several different human papillomaviruses (HPV) have been associated with cancer of the cervix, it is yet to be determined if specific HPV types have clinical or prognostic significance. To address this question, 30 cases of invasive carcinoma (squamous carcinoma, adenosquamous carcinoma, and adenocarcinoma) with HPV DNA sequences detectable in the tissue were analyzed. HPV type was determined by Southern blot DNA hybridization. Clinical information was obtained by chart review, and all biopsy and surgical specimens were reviewed microscopically without knowledge of HPV type. HPV 16 was detected in 14 cases, HPV 18 in 6, and HPV 31 in 2. In eight samples there were distinctly different, but as yet uncharacterized, HPV DNAs. Of the factors evaluated, tumor grade was found to have a statistically significant relationship to HPV type. Eighty-three percent of HPV 18-associated tumors were grade 3 tumors (5 of 6) as compared to only 7% of HPV 16-associated tumors (1 of 14) (P = 0.002). Age at diagnosis and nodal status in relation to HPV type exhibited a trend but were not statistically significant. The mean age of the HPV 18 group was 37 years, compared to 49 years for the HPV 16 group. Similarly, among Stage IB cancers, nodal involvement was associated with 60% of HPV 18 cases (3 of 5) as compared with 36% of HPV 16 cases (4 of 11). These observations suggest that HPV 18 may be associated with a more aggressive form of cervical cancer than other HPV types.