Prediction of lymph node metastases in patients with early squamous cell carcinoma of the cervix uteri by histopathological grading and flow cytometry.

The present study comprises a retrospective investigation of 126 patients with stage IB squamous cell carcinoma of the cervix, and a similar prospective investigation of 53 patients with stage IB and 6 patients with stage IIA disease. Tumour biopsies from these patients were analysed by means of flow cytometry and a semiquantitative histological grading system. The study showed that a combination of a low tumour cell DNA index and a low score value of the grading system indicated a very low risk of regional lymph node metastases (0% lymph node metastases in patients with low scores vs. 24-46% metastases in patients with high scores, P < 0.001). In order to study the reproducibility of the histological grading 20 randomly selected cases were studied blindly by three of the participating pathologists and after discussion of the grading criteria. A kappa coefficient of 722 demonstrated a substantial agreement between the observers. These results suggest that by combining flow cytometry with semiquantitative histological grading, a subgroup of patients with early squamous cell cancer of the cervix uteri may be selected that could be sufficiently treated with simple hysterectomy instead of radical hysterectomy including lymphadenectomy, which, in many oncology centres, is the standard treatment of this patient category.

Does plasminogen activator inhibitor-1 (PAI-1) control trophoblast invasion? A study of fetal and maternal tissue in intrauterine, tubal and molar pregnancies.

Urokinase plasminogen activator, its receptor and the inhibitor PAI-1 are believed to control proteolysis and remodelling of maternal tissue during trophoblast invasion. This system appears to be strictly regulated in normal intrauterine pregnancies whereas tubal and molar pregnancies seem to be characterized by an uncontrolled excessive placental invasion. This study evaluates subcellular PAI-1 by immunohistochemistry in the villous placenta, in the basal plate and placental bed, and in the decidual compartments of normal, tubal and molar pregnancies. PAI-1 was present in villous syncytiotrophoblasts and co-localized focally with fibrin-type fibrinoid on the surface of the chorionic villi. Basal plate and placental bed extravillous interstitial trophoblasts, as well as vascular trophoblasts, were also PAI-1 positive. In the decidua parietalis, PAI-1 was observed in the cytoplasm of the non-invaded decidual cells. In the decidua basalis comprising the basal plate, PAI-1 was seen to be membrane-associated or confined to the extracellular matrix (ECM) facing the invasive front of anchoring villi. The ECM of decidua capsularis and chorion laeve displayed the most pronounced PAI-1 expression towards the maternal interface. In contrast, the majority of placental bed decidual cells adjacent to the interstitial and vascular trophoblasts were PAI-1 negative. Only a few stromal cells distant from the implantation site were PAI-1 positive in the tubal pregnancies and decidualization was not present. Likewise, excessive decidual necrosis and fibrinoid deposition devoid of PAI-1 was a common finding in complete molar pregnancies. These results suggest that PAI-1 defines specific extravillous invasive trophoblasts within the maternal decidua. Moreover, maternal cellular lack of PAI-1 in tubal pregnancies and excessive decidual necrosis in molar pregnancies indicate an uncontrolled placental invasion. The present data indicate that trophoblast invasion is primarily regulated by signals from decidual cells.

Localization and significance of urokinase plasminogen activator and its receptor in placental tissue from intrauterine, ectopic and molar pregnancies.

Urokinase plasminogen activator receptor (uPAR) is a membrane-anchored protein with urokinase plasminogen activator (uPA) as the ligand. This complex induces proteolysis and remodelling of maternal decidua during placental implantation. The presence of uPAR on trophoblasts is supposed to promote adhesion, migration and invasion. In cancer tissue, high levels of uPAR are correlated with a poor prognosis. This immunohistochemical study shows the localization of uPA and uPAR in a prospective design with stereological sampling of fetal and maternal tissue from normal, ectopic and hydatidiform molar (HM) pregnancies. Cytokeratin and Ki67 were used as markers for trophoblasts and proliferating cells. Membrane-bound uPAR was observed on villous non-proliferating intermediate trophoblasts (IT) within cell columns in intrauterine and ectopic pregnancies. The corresponding proliferating IT with cytological atypia sprouting from the chorionic villi in HM was uPAR-negative. uPA but not uPAR was observed in anchoring distal IT at the attachment-point to the basal plate. In the placental bed, extravillous interstitial trophoblasts were uPA-positive but uPAR-negative. The trophoblast giant cells were both uPA- and uPAR-negative. In relation to the maternal vessels, a focal distribution for uPA and uPAR was present in the endovascular and perivascular trophoblasts. The intraluminal trophoblasts overlying endothelial cells were uPAR-positive only. In maternal tissue from intrauterine and molar pregnancies, uPAR was seen in the decidual cells in a zone facing the anchoring villi and the fibrinoid lesions with embedded trophoblasts. In contrast, the stromal cells of the fallopian tube without a decidual reaction facing the implanted gestation were uPAR-negative. Non-invaded decidual, myometrial and muscular tissue of the pregnant uterus and fallopian tube was extensively positive for uPA whereas 'pseudodecidual' cells from the intrauterine evacuate in patients with an ectopic pregnancy only showed a focal and scanty reaction for uPA. When trophoblast invasion of the decidua was present, the decidual cells were uPA-negative. A semi-quantitative assessment of the receptor was estimated in villous IT within cell columns in normal and molar pregnancies but, in conclusion, quantitative evaluation of uPAR cannot be used to predict development of post-molar persistent trophoblastic disease (PTD).

Immunohistochemistry (Ki-67 and p53) as a tool in determining malignancy in smooth muscle neoplasms (exemplified by a myxoid leiomyosarcoma of the uterus).

Smooth muscle tumours of the uterus at times represent a problem as it may be difficult to distinguish between benign and malignant tumours. The myxoid leiomyosarcoma (a rare type of neoplasm) reported here is an example of this. We present a case history and examine the suitability of Ki-67 and p53 as indicators of malignancy. The two antibodies were tested on seven leiomyomas, three atypical (borderline) leiomyomas, seven leiomyosarcomas and the myxoid leiomyosarcoma using microwave oven antigen retrieval. The leiomyomas had the lowest and the leiomyosarcomas the highest proliferation rate. The leiomyomas had no expression of p53, the atypical leiomyomas had a few scattered positive nuclei, and 5/7 of the leiomyosarcomas had overexpression of p53. The myxoid leiomyosarcoma had a positive reaction for p53 in clusters. The results suggest that Ki-67 and p53 might be useful as indicators of malignancy.

A randomized trial comparing two methods of cold knife conization with laser conization.

In a randomized study, 62 women were submitted to cold knife conization with application of Sturmdorf sutures, 60 to cold knife conization without sutures, and 61 to laser conization. Early hemorrhage occurred in 1.6, 13.3, and 6.6% of women, respectively (P less than .05), and late hemorrhage in 15.3, 3.6, and 11.7%, respectively. Considering early and late hemorrhage together, there was no significant difference among the three treatment groups. Dysmenorrhea tended to be more common after application of Sturmdorf sutures, as it was reported by 27.8, 13.2, and 14.3% of patients, respectively, but the difference was not statistically significant. Dysmenorrhea occurred in 13% of the cases with a cone height of 20 mm or less and in 26% of the cases with a cone height greater than 20 mm (P less than .05). Endocervical cells were present significantly more often after sampling with a cytobrush than with a cotton swab (P less than .0001), whereas the method of conization had no influence. In smears obtained with a cytobrush, endocervical cells were present in 88.0, 84.9, and 82.5% of the cases; in smears obtained with a cotton swab, endocervical cells were present in 46.6, 57.7, and 54.5%, respectively. We conclude that cold knife conization without Sturmdorf sutures is about equal to laser conization in overall complications, but the laser is preferable for outpatient treatment because of a lower frequency of early hemorrhage. Sturmdorf sutures should be avoided. Smears at follow-up should be taken with a cytobrush and a wooden spatula.

Near-diploid karyotypes with recurrent chromosome abnormalities characterize early-stage endometrial cancer.

Cytogenetic investigation was attempted on 15 endometrial tumors. Whenever possible, a combination of direct harvesting and short-term culture (with or without prior methotrexate synchronization) was used. The analysis was successful in 13 cases: 12 carcinomas of stage I and one atypical hyperplasia. Clonal abnormalities were found in 10 tumors, whereas the remaining three showed a normal karyotype. The modal chromosome number was near-diploid. The abnormal karyotypes contained relatively simple numerical or structural aberrations in all but one tumor, a serous papillary carcinoma with multiple complex changes as well as cytogenetic evidence of intratumor heterogeneity. Gain of 1q, trisomy for chromosomes 2, 7, 10 (this trisomy was shown by in situ hybridization to be present also in a large number of interphase cells), and 12, and loss of chromosome 22 were recurrent aberrations; these are also the cytogenetic anomalies that have been consistently associated with endometrial carcinomas in previous studies. The utilization of both direct harvesting and short-term culture in several cases increased the frequency with which abnormal karyotypes were found; sometimes aberrations were found by the first method but not by the other, and vice versa. Never were different clonal anomalies found by the two approaches in the same case. Synchronization of the cultures generally led to chromosome preparations with more mitoses and of better quality. Again, no different anomalies were found in synchronized and standard cultures from the same tumor.

Ectopic pregnancy: histopathology and assessment of cell proliferation with and without methotrexate treatment.

OBJECTIVE: To evaluate tubal morphology, trophoblast proliferation, and inflammatory reaction in response to methotrexate (MTX) treatment of ectopic pregnancy (EP). DESIGN: Nonrandomized controlled study. SETTING: Academic hospital. PATIENTS: Archival specimens from 10 EP unsuccessfully treated with MTX and 10 cases primarily treated by surgery. INTERVENTIONS: Ki67/hCG and Ki67/human placental lactogen double immunohistochemical methods were used to examine trophoblastic spread, placentation, hormone production, decidualization, vascular invasion, hemorrhage, rupture, and proliferative index of the cytotrophoblast. B and T-lymphocyte responses were evaluated by CD3 and CD20. RESULTS: Trophoblastic spread and placentation were confined to the tubal mucosa after MTX treatment, whereas invasion of the muscularis and subserosa was common in the controls. The proliferative index was reduced (19 percent versus 93 percent), although a high proliferative index was found in two of three cases complicated by rupture. Polar proliferation of Ki67-positive cytotrophoblast toward the implantation site was abolished in MTX-treated cases. Decidual reaction was not observed. No correlation was observed between the above-mentioned findings and gestational age, level of beta-hCG, dose of MTX, or interval to surgery. CONCLUSION: Trophoblastic spread, differentiation, and invasion were compromised by MTX treatment. Methotrexate seems to decrease cytotrophoblast proliferation. Whether a missing decrease in proliferation index reflects treatment failure awaits a larger population-based study.

Mucinous cystadenocarcinoma in combination with hemangiosarcoma in the ovary.

The ovary is the sixth most frequent site of cancer in women in Denmark with an incidence of approximately 600 cases per year. Carcinomas predominate whereas sarcomas are rare. We describe a case of the combination mucinous cystadenocarcinoma and hemangiosarcoma in a 37-year old woman, who had a right-sited oophorectomy because of a cyst. Clinically there was no suspicion of malignancy. The macro- and microscopic findings are described as well as the immunohistochemical stainings performed to confirm the diagnosis. The case shows the importance of careful sampling at the macroscopic examination, especially from areas with a striking appearance.

Reproducibility and prognostic value of histologic type and grade in early epithelial ovarian cancer.

From September 1981 to September 1986, 417 consecutive treated patients with epithelial ovarian cancer FIGO stage I and II were registered by the Danish Ovarian Cancer Group (DACOVA). Typing and grading were primarily performed by several pathologists, with and without training in gynecologic pathology. Review typing by one specially trained pathologist showed an agreement rate of 72% for serous and endometrioid carcinoma, 86% for mucinous and 100% for clear cell carcinoma. The agreement rate was calculated for patients primarily classified by pathologists trained in gynecologic pathology and for patients primarily classified by pathologists with and without training. The agreement rate was not better for the group of pathologists with special training in gynecologic pathology. Grading was performed according to two classifications: one based on architectural pattern and one on combined criteria. Review grading showed an agreement rate of 77% for architectural classification and an agreement rate of 52% for combined classification. The agreement rate between the two grade classifications at review was only 62%. Combined grading showed a significant tendency towards classifying more tumors as low grade. All grade classifications had prognostic value. The poor agreement rate of both type and grade even when performed by pathologists with expertise in gynecologic pathology, calls for a better and more reproducible characterization of malignant ovarian tumors.

Prognostic factors and adjuvant treatment in early epithelial ovarian cancer.

Four hundred and ten patients with epithelial ovarian cancer FIGO stages I and II were registered by a Danish multicenter study group (The Danish Ovarian Cancer Group - DACOVA). Two-thirds were stage I, the most frequent substage was Iai which was the classification in 27%. Five-year survival for stage I was 72%, and 38% for stage II. Multivariate analysis showed that age, stage, residual tumor, histologic grade and adjuvant treatment had prognostic value. For stage, three significantly different groups could be identified: (1) stage Iai, (2) stage Iaii-Ic, and (3) stage II. Histologic grade showed a significant survival difference between all grades. Adjuvant treatment had a moderate but significant impact on survival. Patients in stage Iai had a good survival with surgery alone and will probably not benefit from adjuvant therapy. Adjuvant treatment improved survival for the remaining patients in stages I and II without residual tumor. A difference between treatment modalities was not observed. However, the data need to be confirmed by a randomized trial. Patients in stage II with residual tumor should be treated as stage III.

Primitive neuroectodermal tumor (PNET) of the uterine cavity.

The occurrence of primitive neuroectodermal tumors located in the uterus is extremely rare. Eight cases have been described in the literature, and with the addition of this ninth case, we summarize treatment and outcome of PNET located in the uterine cavity.

A cost-effectiveness analysis of cervical cancer screening: health policy implications.

This paper presents a framework for comparison of screening programme designs, based on efficiency and cost effectiveness criteria. The design parameters, such as choice of screening interval, which population segments to screen and expected participation rates in the selected population segments, are varied simultaneously. The costs and effects for a range of existing and hypothetical screening programmes against cervical cancer are estimated, using a mathematical simulation model. On the basis of these estimates average costs per life year and marginal costs per life year are calculated for a range of programmes. These calculations result in the definition of a range of inefficient programmes. Moreover, it is illustrated that the cost effectiveness of the efficient screening programmes decreases at an increasing rate as programmes are intensified either by way of shortening the screening interval or extending the target population segment to encompass the very young and/or the very old. The conclusion of this paper is that one should probably not extend screening programmes against cervical cancer beyond screening women in the age group 25-59 years every 4 years. In addition, increasing the participation rate of this group is a more cost effective way of increasing the number of life years gained, rather than extending the target group or decreasing the screening interval.

Efficacy of the cytobrush versus the cotton swab in the collection of endocervical cells.

Cervical smears should contain endocervical cells to be accepted as adequate for a cytologic diagnosis. Before this study was undertaken, one-third of the smears received in the Cytology Laboratory of Odense University Hospital were inadequate. In an attempt to increase the rate of adequate smears, a randomized study was undertaken to compare the efficacy of the combined spatula-Cytobrush method to that of the spatula-cotton swab method traditionally used by doctors in Denmark. The incidence of smears containing cylindrical and/or metaplastic cells was 89% by the spatula-Cytobrush method as compared to 62% by the spatula-cotton swab method (P less than .001). There were large differences between the rates of adequate smears from the various doctors when using the spatula-cotton swab method (range, 14% to 82%); these differences were far less when using the spatula-Cytobrush method (range, 75% to 100%). A large-scale application of the spatula-Cytobrush method should result in fewer repeat smears required and fewer false-negative smears.

Analysis of cervical smears obtained within three years of the diagnosis of invasive cervical cancer.

The cytologic histories of 376 women presenting with invasive carcinoma of the cervix were analyzed. In total, 202 (53.7%) of these women had had 355 smears taken during the three years preceding presentation. All 320 smears with an original cytologic diagnosis of less than cancer were reviewed. The original cytologic diagnosis was low in 95 (30.6%) of 310 adequate smears. Originally, 96 (30.9%) of the adequate smears were evaluated as negative; at review, only 55 (17.5%) of the adequate smears were evaluated as negative. Comparing the review diagnoses to the 355 total smears, the rates of negative smears were 13.5% (42 of 310) for squamous-cell carcinoma, 30.0% (12 of 40) for adenocarcinoma and 20.0% (1 of 5) for adenosquamous carcinoma (P less than .05). The cellular composition of the smear was significantly related to the cytologic detection of abnormalities: endocervical cylindrical and/or metaplastic cells were seen in only 45.5% of smears diagnosed as negative, but in 84.4% and 97.8% of smears diagnosed as atypia and cervical intraepithelial neoplasia, respectively P less than .00001). Smears without endocervical cells should be considered inadequate and should be repeated.

[Evaluation of PAPNET--a semiautomated system used in the screening against cervical cancer]. / Evaluering af PAPNET--et semiautomatisk screeningssystems anvendelse i screening mod livmoderhalskraeft.

The PAPNET-system is a current example of automated technological progress in the pathological laboratory field. As the first Department of Pathology in Denmark, we have tested the applicability of this semi-automatical screening system in screening against cervical cancer. 3000 prospectively selected cervical smears were entered into the project. 1500 of these were first prescreened by the use of PAPNET and the negative slides were then manually rescreened. The remaining 1500 slides consisted of manually screened smears diagnosed as negative or inadequate. They were subsequently rescreened by the use of PAPNET. We only found one false negative smear in each group. Compared with histological follow-up the diagnoses CIN 1-3 were histologically confirmed in both groups. The PAPNET-assisted screening of cervical smears is faster, more valid and less fatiguing than the conventional screening method. Nevertheless, our results show no diagnostic quality improvement by the use of PAPNET. This is probably due to a strict screening procedure and a limited work load of a maximum of about 40-50 slides per cytotechnologist a day in our laboratory.

[Costs and effects of alternative screening programs against cervical cancer]. / Omkostninger og effekter af alternative screeningsprogrammer mod livmoderhalskraeft.

This paper presents a framework for comparison of screening programme designs, based on efficiency and cost effectiveness criteria. Design parameters such as choice of screening interval and which population segments to screen are varied simultaneously. The costs and effects for a range of existing and hypothetical screening programmes for cervical cancer are estimated, using a mathematical simulation model. On the basis of these estimations incremental costs per life year are calculated for a range of programmes. Efficiency and cost effectiveness criteria indicate that extending screening programmes for cervical cancer beyond screening women in the age group 25-59 years every four years may not be optimal.

[Atypical cervix uteri smears--consequences?]. / Cytologisk atypi i cervix uteri--konsekvens?

Among 37,992 cervical smears (725 (1.9%)) were found to be atypical. All atypial smears were referred for colposcopically guided biopsies and cervical abrasio within three months. This is an expensive and cumbersome procedure. In order to obtain a more differentiated follow-up procedure the atypical smears were divided into two groups without knowledge of the later histological diagnosis on biopsy: "Atypia, probably reactive" and "atypia, probably CIN (cervical intraepithelial neoplasia)". In the latter group the subsequent biopsies showed significantly more CIN than in the former (60.4% against 15.7%). We find it useful to divide the atypical smears into two groups in our daily routine work with a different follow-up procedure: "Atypia, probably reactive" to be followed by a repeat smear and "atypia, probably CIN" to be followed by colposcopically guided biopsies and cervical abrasio.

[Complete invasive mole in a 50-year old woman]. / Komplet invasiv mola hos en 50-årig kvinde.

A 50-year-old woman was admitted for hysterectomy due to persistent vaginal bleeding and enlargement of the uterus. Before operation a significant increased beta-HCG was measured. Histologic examination of uterine contents obtained by aspiration showed trophoblastic disease. An decrease in beta-HCG was registered postoperatively. However, two weeks later it rose again and the patient started treatment with methotrexate. It is recommended that the treatment of patients with invasive gestational trophoblastic disease is centralized.

[Screening against cervical cancer. Experiences, attitudes and knowledge of women in the county of Funen]. / Screening mod livmoderhalskraeft. Fynske kvinders erfaringer, holdninger og viden.

Questionnaires on women's attitudes and knowledge of cervical screening in the County of Funen were mailed to a sample of 1505 attenders aged 23-59 years, stratified on age and residence. A high proportion of attenders (80.4%) answered the questionnaire. Two-thirds of the women had been informed about the screening program before they received the invitation to participate. Generally the women were satisfied with the introduction to the screening program. However, the majority of the attenders were not satisfied with the way they received the result. They wanted the result no later than two weeks after the test was done, and they wanted the result from their GP. Independent of age and education the majority (about 90%) had a good general knowledge (knew that the smear is taken from the cervix; that early diagnosis is important; that cervix cancer can be treated). However the specific knowledge was lower and significantly associated with education (e.g. 43% versus 63% could identify the cervix on a drawing of the uterus among women with respectively low and high levels of school education). Furthermore, the majority were of the opinion that the test should be done more frequently than every three years as recommended by the National Health Board.

[Follow-up of non-negative cervical cytological smears in the county of Funen]. / Opfølgning af ikkenegative cervixcytologiske prøver i Fyns Amt.

The outcome of screening for cervical cancer in the county of Funen was evaluated in two sequential periods (1.7.-31.12.1989 and 1.7.-31.12.1992), comprising 17,493 and 18,135 respectively. About 10.5% of the screened women had a define non-negative smear. From the first and the second period 80% and 85.1% of the non-negative smears respectively were followed up within six months. The follow-up of positive smears was 96% in both periods. Four point nine percent and 3.3% respectively of the non-negative smears were not followed up within 18 months. No women were actually lost in the screening system, unless they renounced further follow-up themselves. The follow-up was improved from the first to the second period, presumably as a result of a better general acquaintance with the screening procedures. The study indicates that reorganization of a screening programme requires both time and adjustment. Moreover, it is important that a successful screening programme frequently adjusts its procedures.