Ovarian cancer. an institutional review of patterns of care, health insurance and prognosis.

The purpose of this study was to investigate the prognostic importance of the health insurance status in 145 consecutive patients with ovarian cancer diagnosed between 1984 and 1996. All patients had basic (Type III) insurance to cover outpatient treatment and hospital expenses for a per diem flat fee; some patients had one of two types of supplemental private insurance (Type I and Type II) to cover the treatment by physicians of their choice and fee-for-service hospital treatment. The prognostic impact of health insurance was evaluated by multivariate statistical methods. The median follow-up was 81.9 months (range: 21-181); the 5-year probability of survival was 72% (standard error of the mean (SEM) 9.8%) for stage I, 53% (SEM 16.2%) for stage II, 17% (SEM 5. 9%) for stage III and 11% (SEM 5.5%) for stage IV cancer. Age, stage, histological grade and debulking surgery were independent predictors of survival in multivariate proportional hazards regression analysis. Patients with private insurance were younger and received more chemotherapy than patients with basic insurance. In multivariate analysis, insurance was an independent predictor of survival: patients with Type II insurance had a hazard ratio of 2.31 (95% confidence interval (CI): 1.05-5.04), and patients with Type III insurance had a hazard ratio of 3.30 (95% CI 1.52-7.17) compared with the reference group of Type I insured patients. Health insurance status was an independent predictor of survival in ovarian cancer. Research is needed to devise strategies to improve the medical care of patients with basic insurance.

Pelvimetry by magnetic resonance imaging as a diagnostic tool to evaluate dystocia.

OBJECTIVE: To test the clinical value of magnetic resonance imaging (MRI) pelvimetry for the diagnosis of cephalopelvic disproportion. METHODS: All deliveries from January 1993 through December 1994 were reviewed to identify 42 nulliparas at term with vertex presentation and cesarean delivery due to dystocia. Complete data were available for 41 women, and subjects were divided into the following two subgroups, according to clinical data: "cephalopelvic disproportion" (n = 28) and "failure to progress" (n = 13). Ten nulliparous women with uncomplicated vaginal delivery served as controls. Pelvimetry data from postpartum MRI were correlated with fetal and neonatal dimensions to evaluate various criteria for the diagnosis of cephalopelvic disproportion. RESULTS: Comparing both the fetal head volume derived from antepartum ultrasound assessment and the neonatal head volume (postpartum measurement) with maternal pelvic capacity determined by MRI, cephalopelvic disproportion (head volume exceeding pelvic capacity) indicated that 25 and 27, respectively, of the 28 women had been clinically diagnosed correctly with cephalopelvic disproportion, corresponding to sensitivities of 89% and 96%, respectively. Fetal head volume was not larger than pelvic capacity in any of the women in the control group. In seven of the 13 women diagnosed as "failure to progress," the fetal head volume exceeded the pelvic capacity. CONCLUSION: A fetal head volume estimate exceeding MRI-measured pelvic capacity is a frequent finding in nulliparas with cesarean birth due to cephalopelvic disproportion. An appropriate prospective study to determine the benefits of an antepartum diagnosis of cephalopelvic disproportion in high-risk nulliparas is warranted.

Clear cell adenocarcinoma of the cervix associated with a rare genitourinary malformation.

BACKGROUND: Cervical adenocarcinoma and genitourinary malformations are relatively common disorders, yet their coexistence is rare. CASE: A 49-year-old woman developed clear cell adenocarcinoma in the atretic hemicervix of a communicating uterus type 7 and had ipsilateral renal agenesis. Compared with the unaffected right hemicervix, only the tumor-involved glands of the atretic left hemicervix contained ciliated tuboendometrial cells. Four and a half years after radical hysterectomy and pelvic radiation, she showed no evidence of recurrence. CONCLUSION: In contrast to current opinion, communicating uteri type 7 are associated with ipsilateral renal agenesis. Our histologic findings support the hypothesis that tuboendometrial cells are the cells of origin for cervical clear-cell adenocarcinoma.

Comparison of transvaginal ultrasonography and endometrial biopsy in endometrial surveillance in postmenopausal HRT users.

OBJECTIVES: To compare transvaginal ultrasonography with histological findings in endometrial evaluation of postmenopausal women using hormone replacement therapy and to evaluate endometrial safety of three hormone replacement therapy regimens. METHODS: In a randomized, comparative study in postmenopausal women, endometrial safety was evaluated using (1) no hormone replacement therapy, (2) oral micronized 17 beta-estradiol/oral sequential dydrogesterone, (3) transdermal 17 beta-estradiol/oral sequential dydrogesterone, or (4) oral tibolone. 85 Non-hysterectomised subjects underwent transvaginal ultrasonography immediately before Pipelle biopsy at baseline and subsequently after 12 and 24 months. Endometrial thickness and uterine dimensions were determined by transvaginal ultrasonography, and endometrial thickness (double-layer) was compared with biopsy results. RESULTS: Endometrial evaluation was conveniently performed by transvaginal ultrasonography, and endometrial thickness correlated well with biopsy findings. If endometrial thickness was < 5 mm, the endometrial biopsy sample was either inactive/atrophic or insufficient for histopathological diagnosis. Hyperplastic or malignant changes were not reported. After 24 months, endometrial thickness was increased both in the oral (P < 0.001) and transdermal (P < 0.001) 17 beta-estradiol/dydrogesterone groups, whereas with tibolone the change in endometrial thickness was not different from controls. CONCLUSION: transvaginal ultrasonography of the endometrium reliably predicts the histological picture in hormone replacement therapy users. Using 5 mm endometrial thickness as cut-off point, more than 75% of biopsies could be avoided. All three hormone replacement therapies were safe with respect to the endometrium. With sequential 17 beta-estradiol/dydrogesterone the expected progestogen-induced secretory pattern was observed, whereas endometrial histology under tibolone closely mimicked the natural atrophic postmenopausal state.

Lymphadenectomy in high risk endometrial carcinoma stage I and II: no more morbidity and no need for external pelvic radiation.

The objectives of this retrospective study were to analyze the morbidity of surgical staging and to evaluate the omission of external radiotherapy in high-risk patients with stage I and II endometrial carcinoma when the lymph nodes were negative. From 1988 to 1996, 63 of 117 patients underwent a pelvic and periaortic lymphadenectomy. The decision to perform lymphadenectomy was influenced by patient general health. Patients with lymphadenectomy had a better physical status (P < 0.0001). Lymphadenectomy increased mean operative time (P < 0.0001) and blood loss (P < 0.01), but there was no increase in postoperative complications. At a median follow-up of 54 months, there was one cuff recurrence in 56 patients. Nineteen high-risk patients without external pelvic radiation had the same disease-free survival rate as 37 low-risk patients (P = 0.1). In the group without lymphadenectomy, the disease-free survival for 18 high-risk patients and 32 low-risk patients was similar (P = 0.21). Surgical staging in properly selected patients does not increase postoperative complications and brachytherapy without external radiotherapy is associated with excellent disease-free survival when the lymph nodes are negative.

Peripheral capillaroscopic findings and blood rheology during normal pregnancy.

Peripheral capillary microscopy and blood rheology where used to investigate circulatory changes during normal pregnancy. The first part of the investigation was designed as a cross-sectional study in which capillary morphology and blood flow in the first (n = 24) and third trimester (n = 15) of pregnancy was compared with non-pregnant controls (n = 15). In the second part a longitudinal comparison of capillaroscopic and hemorheological findings throughout pregnancy was performed in 12 women with four measurements at 10-week intervals. In addition, in this group hemorheological measurements were carried out. Both the cross-sectional as well as the longitudinal group showed a significant increase in capillary blood flow velocity which was already present in the first trimester. Throughout pregnancy a gradual enlargement of the pericapillar papilla was seen, reflecting water retention in the interstitial tissue. At low shear rates a significant increase in viscosity was found at the end of pregnancy both in whole blood and at a standardized hematocrit of 45%. Capillaroscopy appears to be an appropriate method to study circulatory changes throughout pregnancy and its value as a diagnostic tool to detect early pathological developments is the objective of a future investigation.

[Evaluation of tumor extension in invasive cancer of the uterine cervix. Diagnostic evaluation of cervix cancer]. / Bilan d'extension tumorale lors de cancer invasif du col utérin. Bilan diagnostique et cancer du col.

Cancer of the uterine cervix accounts for approximately 30% of deaths from malignancies in gynecology and this rate has remained unchanged for more than 40 years. The most important prognostic factor is the extent of the disease at the beginning of treatment. There is, however, a discrepancy of some 50% between clinical and postoperative staging. The aim of this study was to evaluate different diagnostic investigations leading to the preoperative classification (FIGO) of 261 patients with cervical cancer. Data of presurgical clinical and radiological examinations were compared with postoperative histopathological findings. Rectovaginal palpation and computerized tomography (CAT) both showed a positive predictive value of 60%. The performance of CAT and lymphography in the diagnosis of lymph node metastasis was poor with positive predictive values of 36.3 and 20%, respectively. In the absence of parametrial infiltration on palpation, cystoscopy and rectoscopy are superfluous since they are always normal. Urography, because of the possibility to show the topographic anatomy of the urinary tract, was justified in all cases. The value of surgical staging and more recent techniques such as sonography and magnetic resonance is discussed.

[Myoma in pregnancy--a case report and a literature review]. / Myome in der Schwangerschaft--ein Fallbericht und eine Literaturzusammenstellung.

We report the complications of uterine leiomyomas during pregnancy in a case report and a review of the literature. The major complication is the syndrome of painful myomas. Other problems are premature labor, abruptio placentae and postpartum hemorrhage. The method of delivery seems not to be influenced by uterine myomas. Leiomyomas are no contraindication for pregnancy, but intensive antenatal care is advised.

[Terodiline in the treatment of stress incontinence in women]. / Terodilin in der Behandlung der Dranginkontinenz Frau.

Terodiline combines simultaneously a parasympatholytic and a calcium antagonistic effect and can be used positively for the treatment of urge-incontinence of women. 44 female patients with an urge-incontinence have been examined urodynamically before and after a six-week treatment with terodiline. After therapy the urodynamic parameters ameliorated significantly. A subjective amelioration or even a healing of the urge symptomatic occurred in 86.4% of the patients. The side effects were minor.

[Discrepancy in histopathological findings of curettage material and hysterectomy specimens in malignant tumors of the uterine body]. / Diskrepanz der histopathologischen Befunde von Kürettagematerial und Hysterektomiepräparat beim Malignom des Corpus uteri.

The clinical staging of the malignoma of the uterine corpus according to the FIGO classification corresponds in only 85.7% in stage I and 35.7% in stage II to the histopathologic staging after operation. Tumor grading and histology from D and C differ in 31.8% and 9.4% respectively from the hysterectomy specimen. We propose therefore to prefer surgical and histopathological staging to the pure clinical FIGO-staging in order to plan adjuvant therapy and for comparing therapeutic results of different patient groups as well.

[Secondary prevention in coronary diseases. Viewpoint of the gynecological endocrinologist]. / Sekundärprophylaxe bei Koronarerkrankungen. Sicht des gynäkologischen Endokrinologen.

Although reduction of cardiovascular risk by estrogen substitution in the menopause has not been proven by a prospective randomized study the results of the present epidemiologic studies with the most various methodological approaches leave hardly any doubt about such a protective effect. Furthermore the published data show that women with cardiovascular risk factors or with a preexisting cardiovascular disease benefit more from estrogen substitution than healthy women. Addition of gestagen in non hysterectomized women for the reduction of increased risk for endometrial cancer seems to impair the benefit for cardiovascular risk only minimally if at all.