Surgical Methods for the Treatment of Uterine Fibroids - Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG.

The appropriate surgical technique to treat patients with uterine fibroids is still a matter of debate as is the potential risk of incorrect treatment if histological examination detects a uterine sarcoma instead of uterine fibroids. The published epidemiology for uterine sarcoma is set against the incidence of accidental findings during surgery for uterine fibroids. International comments on this topic are discussed and are incorporated into the assessment by the German Society for Gynecology and Obstetrics (DGGG). The ICD-O-3 version of 2003 was used for the anatomical and topographical coding of uterine sarcomas, and the "Operations- und Prozedurenschlüssel" (OPS) 2014, the German standard for process codes and interventions, was used to determine surgical extirpation methods. Categorical qualifiers were defined to analyze the data provided by the Robert Koch Institute (RKI), the German Federal Bureau of Statistics (DESTATIS; Hospital and Causes of Death Statistics), the population-based Cancer Register of Bavaria. A systematic search was done of the MEDLINE database and the Cochrane collaboration, covering the period from 1966 until November 2014. The incidence of uterine sarcoma and uterine fibroids in uterine surgery was compared to the literature and with the different registries. The incidence of uterine sarcoma in 2010, standardized for age, was 1.53 for Bavaria, or 1.30 for every 100 000 women, respectively, averaged for the years 2002-2011, and 1.30 for every 100 000 women in Germany. The mean incidence collated from various surveys was 2.02 for every 100 000 women (0.35-7.02; standard deviation 2.01). The numbers of inpatient surgical procedures such as myoma enucleation, morcellation, hysterectomy or cervical stump removal to treat the indication "uterine myoma" have steadily declined in Germany across all age groups (an absolute decrease of 17 % in 2012 compared to 2007). There has been a shift in the preferred method of surgical access from an abdominal/vaginal approach to endoscopic or endoscopically assisted procedures to treat uterine fibroids, with the use of morcellation increasing by almost 11 000 coded procedures in 2012. Based on international statements (AAGL, ACOG, ESGE, FDA, SGO) on the risk of uterine sarcoma as an coincidental finding during uterine fibroid surgery and the associated risk of a deterioration of prognosis (in the case of morcellation procedures), this overview presents the opinion of the DGGG in the form of four Statements, five Recommendation and four Demands.

Vaginal Vault Suspension at Hysterectomy for Prolapse - Myths and Facts, Anatomical Requirements, Fixation Techniques, Documentation and Cost Accounting.

Vaginal vault suspension during hysterectomy for prolapse is both a therapy for apical insufficiency and helps prevent recurrence. Numerous techniques exist, with different anatomical results and differing complications. The description of the different approaches together with a description of the vaginal vault suspension technique used at the Department for Urogynaecology at St. Hedwig Hospital could serve as a basis for reassessment and for recommendations by scientific associations regarding general standards.

Dilution of dye improves parametrial SLN detection in patients with cervical cancer.

OBJECTIVE: Aim of this study to improve the detection rate of parametrial sentinel nodes in patients with early cervical cancer by using a new dosage of blue dye in a randomized trial. METHODS: Standard labelling volume of 4 ml Patent Blue was compared to 2 ml Patent Blue diluted with 8 ml NaCl 0.9% in 60 patients using a randomized protocol. Tc-99 was not applied in any patient. All patients underwent open lymphadenectomy. RESULTS: In each arm 30 patients were enrolled. Overall detection rate of sentinel nodes was 93.3%. Both groups did not differ with regard to patient's age, BMI, tumor stage, number of lymph nodes harvested, number of sentinel nodes detected and detection rate. Significantly more patients with parametrial sentinel nodes were detected in the diluted protocol (37.0% vs. 10.3%) which is due to the lateral part of the cardinal ligament (29.6% vs. 6.9%). CONCLUSION: In our study overall detection of sentinel nodes using a dye was high. The diluted solution of Patent Blue led to a higher detection rate of parametrial sentinel nodes. These findings might help explain the discrepancy between the high reported rate of parametrial lymph nodes in anatomical studies compared with the low rates in clinical sentinel series.

[Progress in the early diagnosis of breast carcinoma during the years 1981-1990. Results of a longitudinal study]. / Fortschritte in der Früherkennung des Mammakarzinoms in den Jahren 1981-1990. Ergebnisse einer Longitudinalstudie.

BACKGROUND AND OBJECTIVE: Current meta-analyses have left in doubt whether general breast screening increases survival rate. This study investigated whether efforts at early diagnosis of cancer in the 1980s have had an effect on average tumor size at first diagnosis and on survival rate. PATIENTS AND METHODS: From 1981 to 1990, 1656 consecutive patients (average age 56.6 years) at the I. Women's Clinic at the Ludwig-Maximilian University of Munich and the Women's Clinic Berlin-Charlottenburg were operated on for primary breast cancer. In a retrospective analysis, average tumor size at the primary operation and survival rate were determined for two periods: 1981-1985 (n=849) and 1986-1990. Mean follow-up time was 63 months. RESULTS: There was no difference between the two cohorts regarding age (p = 0.77) and axillary node status (p = 0.14). During the follow-up period there was a gradual decrease in the tumor size at first diagnosis. (Pearson's correlation coefficient: -0.79, p < 0.001). Average tumor size in those operated on was 25 mm up to 1985, and 21 mm after 1986 (p < 0.001). Until 1985, the initial reason for mammography was the planned subsequent operation in 19% of patients (n = 164), and in 27% (n = 215; p < 0.001) since 1986. But there was no statistically significant rise in disease-specific survival rate (log rank, p=0.48). Multivariate analysis confirmed the conventional prognostic parameters, such as tumor size (relative risk 2.21) and axillary lymph node metastases (relative risk 3.57), but not the period of follow-up (p=0.90). CONCLUSION: During the stated periods of follow-up there was a significant decrease in average tumor size at initial diagnosis. But this did not result in any demonstrably better disease-specific survival rate.

A new once-daily formulation of tolterodine provides superior efficacy and is well tolerated in women with overactive bladder.

This study evaluated the efficacy and tolerability of new extended-release (ER) tolterodine for the treatment of overactive bladder in women. In this subpopulation analysis of a double-blind multicenter trial, 1235 female patients were randomized to oral therapy with tolterodine ER 4 mg once daily (n=417), tolterodine IR 2 mg twice daily (n=408) or placebo (n=410) for 12 weeks. Both formulations reduced the mean number of urge incontinence episodes per week (both P=0.001 vs placebo); tolterodine ER was more effective than tolterodine IR (P=0.036). Both formulations significantly improved all other micturition chart variables compared to placebo. Dry mouth was the most common adverse event. There were no safety concerns. Toltrodine ER 4 mg once daily is effective and well tolerated in the treatment of women with overactive bladder, and reduces urge incontinence episodes more than the existing IR twice-daily formulation.

Antibiotic treatment to prevent urinary tract infections after urodynamic evaluation.

The aim of the study was to determine the efficacy of cotrimoxazole administration after urodynamic testing to prevent urinary tract infections. In a single-blind prospective randomized study 94 women who attended for urodynamic evaluation were included. After multichannel urodynamic testing, including two catheterizations, the women received a single dose of cotrimoxazole or placebo. A clean-catch urine specimen was tested for infection after 1 week. Seventy women returned a urine specimen after 1 week: 2/37 (5.4%) in the treatment and 2/33 (6.1%) in the placebo group had acquired a new urinary tract infection after urodynamics. One major and one minor adverse reaction to cotrimoxazole were reported. The power of the sample size was unfortunately too small to draw conclusions as to the efficacy of prophylaxis.

Quality of life influenced by primary surgical treatment for stage I-III breast cancer-long-term follow-up of a matched-pair analysis.

BACKGROUND: Breast-conserving therapy has been demonstrated to be just as safe and a less disruptive experience compared with mastectomy for surgically manageable breast cancer. There is, however, no agreement in the literature about the impact of these procedures on several important aspects of quality of life (QOL). The purpose of the present study is to compare the long-term impact of these two surgical approaches on QOL in patients with identical tumor stages and to suggest possible shortcomings of the standard QOL questionnaires. METHOD: Between August 1999 and May 2000, QOL questionnaires were answered by 152 pair-matched patients at the I. Frauenklinik, Ludwig-Maximilians University Munich, as part of routine follow-up examinations. The pairs of patients, each consisting of one patient after mastectomy and one after breast conservation, were selected according to the highest degree of equivalence in tumor stage. All patients had been initially treated for stage I-III breast cancer without evidence of distant metastases. The QOL was evaluated by using the QLQ-C30 questionnaire version 2.0 of the EORTC Study Group on Quality of Life. We formulated seven additional questions about the patients' satisfaction with the primary surgical treatment modality as viewed from their current perspective. The QOL questionnaires were answered after a median interval of 46 months following primary treatment. RESULTS: Tumor stage, prognostic factors, and adjuvant systemic treatment were well balanced between the two groups. No differences between the two groups were observed in terms of all QOL items measured by the QLQ-C30. Our additional questions, however, revealed that patients in the mastectomy group were less satisfied with the cosmetic result of their primary operation (P < .0001), were more likely to feel basic changes in their appearance (P < .0001), and were more likely to be emotionally stressed by these facts (P < .0001). From their perspective at the time of completing the questionnaires, 11 patients in the mastectomy group (15%) would decide differently about the surgical treatment modality, compared with only 3 patients (4%) in the breast conservation group (P = .025). CONCLUSION: While the primary surgical treatment modality seems to have no long-term impact on general QOL, certain body-image-related problems may be caused by mastectomy. Standard measuring instruments for QOL may fail to detect differences in satisfaction and adaptation with the primary surgical treatment modality.

Matched pair analysis of survival after chest-wall recurrence compared to mammary recurrence: a long-term follow up.

BACKGROUND: Local recurrence remains a major concern after primary treatment of breast cancer and has a major impact on subsequent survival. While most studies report a poorer survival rate in patients with a local recurrence after mastectomy than after breast conservation, it remains controversial whether different risk profiles at the time of primary diagnosis may account for this difference. METHOD: Matched pair analysis of 134 patients with newly diagnosed locoregional recurrence of breast cancer without evidence of systemic disease. Matching criteria included the primary surgical treatment, tumor size, nodal status, and age. The significance of various prognostic parameters at the time of primary diagnosis and at the time of recurrence were evaluated, by univariate and multivariate analyses, with respect to survival after recurrence. The median follow-up was 8.4 years. RESULTS: Risk factors at the time of presentation, such as tumor size and lymph node status, were comparable between both groups. Local recurrence occurred on an average 9 months earlier in patients after mastectomy (P = 0.08). Univariate analysis showed that lymph node status (P = 0.0001) and disease-free interval from primary treatment to local recurrence (P = 0.0002) were the most significant single prognostic factors for subsequent survival after local recurrence. The primary surgical treatment modality was shown to be of marginal statistical influence (only P = 0.05). CONCLUSION: Local recurrence after mastectomy seems to be associated with worse survival than after breast-conserving therapy. Early onset of chest-wall recurrence, moreover, represents the highest independent risk for cancer-associated death.

Evaluation of pelvic floor muscle strength using four different techniques.

The aim of the study was to evaluate whether four different techniques were able to correctly measure pelvic floor muscle strength only. Sixteen volunteers performed a set of muscle contractions using the pelvic floor muscles (PFM) only, the abdominal muscles with and without PFM, gluteal muscles with and without PFM, adductor muscles with and without PFM and Valsalva maneuver with and without PFM. Pelvic floor muscle strength was evaluated by digital palpation, intravaginal EMG, pressure perineometry and perineal ultrasound. A 'non-pelvic muscle induced' reading was defined as a significant increase even though the pelvic floor muscles were not contracted. Results were as follows: isolated abdominal muscle contraction: non-pelvic muscle induced readings in 3/8 women with EMG and in 3/8 with pressure perineometry; isolated gluteal muscle contraction: non-pelvic muscle induced readings in 1/2 women with EMG perineometry; isolated adductor muscle contraction: non-pelvic muscle induced readings in 6/11 women with EMG perineometry and in 2/11 women with pressure perineometry; Valsalva maneuver: non-pelvic muscle induced readings in 4/9 women with EMG perineometry and 9/9 women with pressure perineometry. It was concluded that EMG and pressure perineometry do not selectively depict pelvic floor muscle activity.

[Chemotherapy-associated myelosuppression in gynecological oncology]. / Chemotherapieassoziierte Myelosuppression in der gynäkologischen Onkologie.

INTRODUCTION AND OBJECTIVE: A clinically important myelosuppression due to adjuvant chemotherapy is seen more frequently as dosage is intensified and new drugs are used. The assessment of the cytopenia expected is frequently hampered by a lack of directly comparable data. The aim of this study was to compare - in our own patient population - the chemotherapy-associated myelosuppression of four chemotherapeutic regimens used in gynecological oncology. METHODS: 79 patients with primary breast cancer and 26 patients with epithelial ovarian carcinoma underwent cytostatic treatment, and the associated myelosuppression was evaluated by the determination of cytopenia and the need for supportive therapy. The chemotherapy regimens investigated were CMF (cyclophosphamide 600 mg/m(2), methotrexate 40 mg/m(2), 5-fluorouracil 600 mg/m(2), 6xq3w), EC/CMF (epirubicin 90 mg/m(2), cyclophosphamide 600 mg/m(2), 4xq3w, followed by CMF, 3xq3w), DE (docetaxel 75 mg/m(2), epirubicin 90 mg/m(2), 6xq3w) and CC (cyclophosphamide 600 mg/m(2), carboplatin AUC 6, 6xq3w). RESULTS: The EC/CMF and DE regimens were used significantly more frequently for more advanced tumor stages, but there were no differences concerning tumor-dependent prechemotherapeutic myelosuppression. Hemopoiesis was most impaired in the CC group with a mean drop of serum hemoglobin of 1.5 g/dl to the end of the cytostatic treatment; correspondingly, most transfusions of concentrated erythrocytes were needed in this group. The strongest suppression of leukopoiesis was found in the DE group, with a mean drop in leukocyte counts of 6.2 x 10(3)/microliter per cycle; in this group, a mean of 7.6 ready-made syringes with 263 microgram Lenogastrim was used to stimulate leukopoiesis. The severest drop in the mean thrombocyte count, i.e. 171.7 x 10(3)/microliter, was found in the CC group. CONCLUSIONS: The CC regimen impairs thrombo- and erythropoiesis most, whereas the DE regimen causes marked leukopenia. The regimen with the smallest myelosuppression was CMF. No severe cytopenia-associated complications were detected in any of the cases investigated.

Differences between cough and Valsalva leak-point pressure in stress incontinent women.

The aim of the study was to evaluate the relationship between Valsalva leak-point pressure (VLPP) and cough leak-point pressure (CLPP). Sixty women with stress urinary incontinence were included. One woman was excluded from evaluation because of detrusor instability. At a bladder volume of 200-300 mL (mean, 284; standard deviation, 29) CLPP and VLPP were measured in the sitting position. Intra-abdominal pressure was recorded with a rectal balloon catheter. A standardized pad test and multi-channel urodynamics were performed. VLPP was significantly lower than CLPP (58.9+/-27.6 versus 112.5+/-46.9 cm H(2)O, P<0.0001). Although CLPP was negative in two women only, VLPP was negative in 24 of 59 women (40.1%). If intrinsic sphincter deficiency was defined as a leak-point pressure of 65 cm H(2)O, 16.9% of women fulfilled this criterion using the CLPP compared to 35.6% if the VLPP is used. In conclusion, coughing and Valsalva seem to result in a different reaction of the pelvic floor.

Radiotherapy of the chest wall following mastectomy for early-stage breast cancer: impact on local recurrence and overall survival.

INTRODUCTION: Recent studies have renewed an old controversy about the efficacy of adjuvant radiotherapy following mastectomy for breast cancer. Radiotherapy is usually recommended for advanced disease, but whether or not to use it in pT1-T2 pN0 situations is still being debated. This study was designed to clarify whether or not routine radiotherapy of the chest wall following mastectomy reduces the risk of local recurrence and if it influences the overall survival rate. METHODS: Retrospective analysis of patients treated with mastectomy for pT1-T2 pN0 tumors and no systemic treatment. Patients treated with radiotherapy of the chest wall following mastectomy (Group A) are compared with those treated with mastectomy alone (Group B). RESULTS: A total of 918 patients underwent mastectomy. Patients who received adjuvant radiotherapy after mastectomy (n = 114) had a significantly lower risk for local recurrence. Ten years after the primary diagnosis, 98.1% of the patients with radiotherapy were disease free compared to 86.4% of the patients without radiotherapy. The average time interval from primary diagnosis until local recurrence was 8.9 years in Group A and 2.8 years in Group B. The Cox regression analysis including radiotherapy, tumor size and tumor grading found the highest risk for local recurrence for patients without radiotherapy (p < 0.0004). In terms of overall survival however, the Kaplan-Meier analysis showed no difference between the two groups (p = 0.8787) and the Cox regression analysis failed to show any impact on overall survival. CONCLUSION: With observation spanning over 35 years, this study shows that adjuvant radiotherapy of the chest wall following mastectomy reduces the risk for local recurrence in node-negative patients with pT1-T2 tumors but has no impact on the overall survival rate.

Prognostic significance of an increased number of micrometastatic tumor cells in the bone marrow of patients with first recurrence of breast carcinoma.

BACKGROUND: Using cytokeratin (CK) as a histogenetic marker of epithelial tumor cells in the bone marrow of patients with primary breast carcinoma, a subgroup of patients with decreased survival can be identified. This study was designed to evaluate the frequency and prognostic relevance of such cells in patients with recurrent breast carcinoma. METHODS: Bone marrow aspirates from 65 patients were analyzed immunocytochemically for the presence of CK positive cells. A quantitative immunoassay with monoclonal anti-CK antibody A45-B/B3 was used and 2 x 10(6) bone marrow cells per patient were evaluated. For prognostic evaluation the authors calculated a cutoff value of micrometastatic tumor cells by analogy to classification and regression tree (CART) analysis. Patients were monitored prospectively for a median of 37 months (range, 11-63 months). RESULTS: Bone marrow micrometastases were present in 5 of 32 patients (16%) with locoregional recurrence and in 24 of 33 patients (73%) with distant recurrence. The bone marrow status yielded no prognostic indication for patients with locoregional recurrence. In contrast, a cutoff value of 2.5 tumor cells per 1 million bone marrow cells analyzed (2.5 x 10(-6) tumor cells) correlated with a significantly different prognosis for women with distant disease. Patients with metastatic disease and a micrometastatic tumor load of > 2.5 x 10(-6) tumor cells survived for a mean of 6 months (95% confidence interval [95% CI], 2.0-9.1) compared with 17 months (95% CI, 11.6-22.0) for patients with < or = 2.5 x 10(-6) tumor cells (P < 0.0001). Multivariate analysis, allowing for hormone receptor status, disease free interval prior to recurrence, manifestation site of metastases, age, and micrometastases in bone marrow, revealed that bone marrow involvement was an independent risk factor, with a hazard ratio of 7.4 (95% CI, 1.6-13.3) for disease-related death. CONCLUSIONS: An increased number of micrometastases identified in the bone marrow of patients with metastatic breast carcinoma represents an independent prognostic factor that may influence future therapeutic strategies for patients with metastatic breast carcinoma.

Immunohistochemical analysis of Bcl-2 and Bax expression in relation to cell turnover and epithelial differentiation markers in the non-lactating human mammary gland epithelium.

The expression of the apoptosis-related proteins Bcl-2 and Bax was investigated by immunohistochemistry in the normal non-lactating human mammary gland in relation to cell proliferation and apoptosis. In order to characterize individual Bax/Bcl-2-immunoreactive cells, the epithelial markers cytokeratin 14 and 19 and the macrophage marker CD 68 were used. Secretory-like differentiation of epithelial cells was characterized by histochemistry and lectin staining of surface glycoconjugates. Cell proliferation was exclusively found in glandular epithelial cells with broad contact to the ductular lumen, whereas nuclei with apoptosis-related DNA fragmentation were seen predominantly in basally located glandular epithelial cells and in myoepithelial cells. Weak immunoreactivity for Bcl-2 and Bax was present throughout all epithelia, suggesting a balance between pro- and antiapoptotic effects in the majority of epithelial cells. However, specific cells showed a strong staining for Bax or Bcl-2. The strongly Bcl-2-immunoreactive epithelial cells were not identical with proliferating cells, but they resembled them in configuration and in the luminal intraepithelial position. In contrast, the strongly Bax-positive epithelial cells had no or only a narrow contact to the ductular lumen. The different patterns of Bax/Bcl-2 immunoreactivity in specific glandular epithelial cells suggest that there are also different grades of susceptibility towards apoptotic stimuli in individual glandular epithelial cells. We conclude that specific Bax/Bcl-2 expression patterns could reflect particular cell differentiation states, and that the strongly Bcl-2-positive cells in part could represent epithelial stem cells.

Cytokeratin-positive cells in the bone marrow and survival of patients with stage I, II, or III breast cancer.

BACKGROUND: Cytokeratins are specific markers of epithelial cancer cells in bone marrow. We assessed the influence of cytokeratin-positive micrometastases in the bone marrow on the prognosis of women with breast cancer. METHODS: We obtained bone marrow aspirates from both upper iliac crests of 552 patients with stage I, II, or III breast cancer who underwent complete resection of the tumor and 191 patients with nonmalignant disease. The specimens were stained with the monoclonal antibody A45-B/B3, which binds to an antigen on cytokeratins. The median follow-up was 38 months (range, 10 to 70). The primary end point was survival. RESULTS: Cytokeratin-positive cells were detected in the bone marrow specimens of 2 of the 191 control patients with nonmalignant conditions (1 percent) and 199 of the 552 patients with breast cancer (36 percent). The presence of occult metastatic cells in bone marrow was unrelated to the presence or absence of lymph-node metastasis (P=0.13). After four years of follow-up, the presence of micrometastases in bone marrow was associated with the occurrence of clinically overt distant metastasis and death from cancer-related causes (P<0.001), but not with locoregional relapse (P=0.77). Of 199 patients with occult metastatic cells, 49 died of cancer, whereas of 353 patients without such cells, 22 died of cancer-related causes (P<0.001). Among the 301 women without lymph-node metastases, 14 of the 100 with bone marrow micrometastases died of cancer-related causes, as did 2 of the 201 without bone marrow micrometastases (P<0.001). The presence of occult metastatic cells in bone marrow, as compared with their absence, was an independent prognostic indicator of the risk of death from cancer (relative risk, 4.17; 95 percent confidence interval, 2.51 to 6.94; P<0.001), after adjustment for the use of systemic adjuvant chemotherapy. CONCLUSIONS: The presence of occult cytokeratin-positive metastatic cells in bone marrow increases the risk of relapse in patients with stage I, II, or III breast cancer.

Treatment of female urinary incontinence with EMG-controlled biofeedback home training.

The aim of the study was to evaluate the efficacy of pelvic floor training with EMG-controlled home biofeedback in the treatment of stress and mixed incontinence in women. Subjects were recruited from the urodynamic outpatient clinic and performed pelvic muscle training with an EMG-controlled biofeedback device for 20 minutes daily for 6 months. The number of pads used per day, the number of incontinence and urgency episodes, voiding frequency, maximum urethral closure pressure, functional urethral length and pressure/transmission ratio during stress were assessed before and after treatment. Thirty-three patients (13 with stress and 20 with mixed incontinence) completed the study. There was a significant decrease in the number of pads used per day, the number of incontinence and urgency episodes, and the voiding frequency. Twenty-eight patients (85%) reported that they were cured or improved. Urodynamic parameters did not change significantly. It was concluded that home pelvic floor training with EMG-controlled biofeedback is efficient in 85% of patients in alleviating the symptoms of genuine stress and mixed incontinence without causing side effects.

Prognostic relevance of immunohistology, tumor size and vascular space involvement in axillary node negative breast cancer.

OBJECTIVE: Adjuvant treatment for patients with axillary node negative (ANN) breast cancer is controversial because operation alone gives a 70% cure rate. Features which predict recurrence are needed and we therefore evaluated the predictive value of tumor diameter and vascular involvement as well as of estrogen receptors (ER), progesterone receptors (PR), p53, MIB-1, c-erb and PCNA demonstrated by immunohistological staining in 178 patients with ANN breast cancer. Although ER status, tumor diameter and vascular space involvement were significantly correlated to the development of recurrence, their sensitivity, specificity and predictive value were too low to give them clinical value.

Myogenic changes of the levator ani muscle in premenopausal women: the impact of vaginal delivery and age.

The aim of this study was to evaluate the impact of parity and age on histomorphology of the pelvic floor muscles in female cadavers of reproductive age and to find out whether there is evidence of myogenic or neurogenic muscle injury. In a cross-sectional study 45 premenopausal unfixed and fresh female cadavers were studied. Four groups were defined: nulliparous and parous women under the age of 40 and over 40 years of age. The pelvic floor was biopsied at six standardized locations. For evaluation of the quantitative parameters and fiber type identification, actomyosin ATPase at pH 9.4 was used. For histomorphological evaluation, sections were stained with hematoxylin/eosin, van Gieson, and Gomori trichrome. The circumference of type I fibers is significantly larger in nulliparous women younger than 40 years compared to nulliparae older than 40 years. Comparing these groups, the form factor of type II fibers also increases significantly, presenting a more circular cell form. Compared to nulliparae, vaginal delivery led to a significant difference regarding the presence of centrally located nuclei, fibrosis, and variation in fiber diameter. In nulliparous women, these significant changes were also found with increasing age. In women with a history of vaginal delivery, no further increase in these characteristics could be detected with increasing age. Comparing the three different biopsy sites, all three changes were more pronounced in the ventral part. There was no evidence of grouped fiber atrophy, small angulated fibers, or type grouping in any of the biopsy specimens. Aging and vaginal childbirth lead to histomorphological changes of the pelvic floor muscle that are consistent with changes of myogenic origin. Evidence of neurogenic damage could not be demonstrated.

Accuracy of preoperative histology and macroscopic assessment of cervical involvement in endometrial carcinoma.

OBJECTIVE: To compare the diagnostic accuracy between the preoperatively and macroscopically established determination of cervical involvement in endometrial carcinoma. STUDY DESIGN: During the period 1987 to 1991, 154 patients with endometrial cancer were evaluated in a retrospective blind manner with the objective of assessing the diagnostic accuracy of the preoperative (prehysterectomy curettage) and the macroscopic (sectioned surgical specimen) determination of th involvement of the cervix. The results were compared with histological findings of the hysterectomy specimen (gold standard). RESULTS: Preoperative pre-hysterectomy curettage established a sensitivity of 38% and a specificity of 91% whereas the macroscopic findings (gross appearance) confirmed a sensitivity of 50% and a specificity of 95%. A prevalence of 17% for cervical involvement was found. In patients with cervical involvement diagnosed on pre-hysterectomy curettage, a positive predictive value of 45% and negative predictive value of 88% were established. A positive predictive value of 68% and a negative predictive value of 90% resulted from the judgement of the cervical gross appearance. CONCLUSIONS: We conclude that the cervical involvement of endometrial carcinoma diagnosed on pre-hysterectomy tissue is less predictive than the judgement of the intraoperative gross appearance of the cervix.

[Results of adjuvant chemotherapy of operated high risk cervix carcinoma]. / Ergebnisse der adjuvanten Chemotherapie des operierten High-Risk-Zervixkarzinoms.

Patients with carcinoma of the cervix and histologically proven blood vessel invasion have a poor prognosis. At the I. Frauenklinik der Universität München, 34 women were enrolled for a prospective study and were alternatively treated with or without adjuvant chemotherapy (carboplatin and 5-fluorouracil). Of the 28 patients included in the follow-up (14 with/14 without chemotherapy), 12 patients died (5 with/7 without chemotherapy). The disease-free interval was 18.6 months in the group treated with chemotherapy compared to 29.3 months in the group without chemotherapy. There is no statistically significant difference in the survival of patients with blood vessel invasion in relationship to adjuvant chemotherapy following radical hysterectomy.