Suppression of lymphocyte proliferation in vitro by macromolecules in the vesicle fluid and tissue extracts of hydatidiform mole.

This study examines the effects of vesicle fluid and tissue extracts from hydatidiform mole trophoblast on lymphocyte proliferation in vitro. Samples were obtained by direct aspiration of vesicles (hydatidiform mole vesicle fluid (HMF] or homogenization of molar tissues (hydatidiform mole extract (HME] following therapeutic uterine evacuation of hydatidiform mole. Dialyzed and lyophylized HMF pooled from two patients exhibited a 30% suppression (P less than 0.05) of mitogen-induced lymphocyte proliferation at a concentration of 12.5 micrograms protein/ml. Similarly, lymphocyte transformation was significantly suppressed (P less than 0.05) by HME at concentrations of 500 and 250 micrograms/ml. Molecular weight chromatography of HME resolved 4 protein fractions. Fraction 3 (35--50 kDa) and fraction 4 (less than 35 kDa) significantly suppressed mitogen-induced lymphocyte transformation while fractions 1 and 2 demonstrated no immunosuppression. Heat treatment (56 degrees C, 30 min) abolished the immunosuppressive activity of HME as well as fractions 3 and 4. These results suggest that hydatidiform mole trophoblast contains heat-labile macromolecules which suppress mitogen-mediated lymphocyte transformation. Such trophoblast-derived factors may interfere with maternal rejection of the allograft.

Treatment of persistent ectopic pregnancy with methotrexate and leukovorum rescue: a case report.

The incidence of ectopic pregnancy is increasing in the Western world, and this reproductive complication has had an adverse impact on subsequent fertility. Advances in the surgical treatment of ectopic pregnancies have been designed to preserve future reproductive potential, but conservative tubal surgery may fail to completely remove the trophoblast. Described is a case of persistent ectopic pregnancy successfully treated with methotrexate.

Life-threatening neutropenia following methotrexate treatment of ectopic pregnancy: a report of two cases.

BACKGROUND: Medical treatment of ectopic pregnancy with methotrexate is an increasingly common alternative to surgical management. Initial reports of methotrexate therapy described a very low incidence of complications. We report our experience with two patients who developed profound toxicity following methotrexate treatment of ectopic pregnancy. CASE: The first patient received a single dose of methotrexate (50 mg/m2 intramuscularly) for a confirmed ectopic pregnancy. The second patient received three doses of methotrexate (1 mg/kg). Both patients developed life-threatening neutropenia and febrile morbidity requiring hospitalization and supportive care. CONCLUSION: To our knowledge, this is the first description of significant morbidity secondary to bone marrow suppression following methotrexate treatment of ectopic pregnancy. Most patients with ectopic pregnancy who are treated with methotrexate can expect resolution of their symptoms and a low risk of mild complications. However, serious complications after this therapy are possible and may occur even with the single-dose regimen.

Case report: lymphangitic carcinomatosis from cervical carcinoma--an unusual presentation of diffuse interstitial lung disease.

Pulmonary lymphangitic carcinomatosis is an unusual presentation of diffuse infiltrative lung disease. In this report, we present a case secondary to cervical carcinoma that has been previously reported in only four patients. The diagnosis was made by transbronchial lung biopsy.

Effect of blood transfusion in patients with gynecologic malignancy.

OBJECTIVES: To determine the effect of blood transfusion on long-term outcome (disease-free interval, recurrence of disease after treatment, and survival) in women with invasive gynecologic malignancy. METHODS: In this retrospective study, 125 patients with gynecologic malignancy were assessed over a 36-month period. The variable of whether patients received blood transfusion during therapy was used to divide the sample into two groups. RESULTS: There were no differences in the age, ethnicity, and site-stage of tumor of the two groups. Treatments (surgery, radiotherapy, chemotherapy, or multimodal) were similar between the two groups, as were initial hematocrits. The disease-free interval was significantly better in women who did not receive homologous blood (P < 0.001). Life table analysis illustrated that more patients were alive and free of disease if they did not receive blood (P < 0.001). Likewise, persistence-recurrence of cancer was more common in the transfusion group (P < 0.001). Finally, overall survival time was adversely affected by transfusion (P = 0.045). CONCLUSIONS: The use of blood products in patients with invasive gynecologic cancer is associated with enhanced recurrence or persistence of malignancy, a decrease in the disease-free interval, and reduction in the probability of survival without evidence of disease.

Acute urinary retention due to a free-standing broad ligament leiomyoma.

A 38-year-old woman who had used oral contraceptives continuously since age 22 presented with acute urinary retention. Physical examination revealed a bladder outlet obstruction due to a large paravaginal/broad ligament mass. Magnetic resonance imaging (MRI) demonstrated that the mass was separate from the uterus which was confirmed at surgery when an isolated free-standing leiomyoma was removed.

Treatment of unruptured ectopic pregnancy with methotrexate.

Medical treatment is appropriate for patients with an unruptured tubal pregnancy who wish to preserve fertility or have medical problems associated with increased risk of anesthesia. Patients with persistent trophoblast after conservative surgery should be treated with methotrexate rather than undergo a repeat surgery. All nine of our patients with ectopic pregnancies who were treated with MTX were cured with one course of therapy. Little toxicity was observed and subsequent reproductive performance after medical treatment was comparable to that reported in the literature. Direct injection of MTX into an ectopic pregnancy under sonographic control provided an option for treatment which required little anesthesia, reduced the amount of drug and allowed the treatment of a gestation which would otherwise not be considered a candidate for the 3 dose intramuscular injection protocol (see Table 3).

Retroperitoneal fibrosis associated with carcinoma of the cervix: review of the literature.

Microinvasive cervical cancer presented in a woman with retroperitoneal fibrosis in remission following steroid therapy. The cervical lesion was treated surgically with good outcome. Review of the literature documenting this association reveals three other cases, one following and two preceding the diagnosis of retroperitoneal fibrosis. The case reports are reviewed and potential difficulties in the management of these patients are discussed.

Repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus (prespinous) fascia.

OBJECTIVES: We reviewed our experience with the use of iliococcygeus fascia for repair of vaginal vault prolapse. STUDY DESIGN: A retrospective chart review identified 110 patients who had repair of vaginal vault prolapse by suspension of the vagina to iliococcygeus fascia from March 1981 to April 1991. All patients were followed for a minimum of 3 years. RESULTS: Thirty-seven (33.6%) patients had uterine prolapse with enterocele. Posthysterectomy enterocele was present in 73 (66.4%) patients. All had a complex pelvic floor defect including cystocele or rectocele. Mean age was 54.5 +/- 14.6 years and mean parity was 4.1 +/- 3.2 births. Forty-two (38%) were grand multiparous patients. Five were nulliparous. Length of the procedure was 163.2 +/- 11.4 minutes. Estimated blood loss was 358.2 +/- 253.6 ml. Postoperative urinary catheterization was required for 6.1 +/- 4.1 days. Duration of hospital stay was 5.5 +/- 2.0 days. Three patients had hemorrhage > 750 ml and two required transfusion. One bowel injury and one bladder injury occurred. Forty-one patients had postoperative complications. The patients have been followed up for a minimum of 3 years, and four have had recurrent defects. All recurrent defects involved the anterior vaginal wall. CONCLUSIONS: Suspension of the vagina to the iliococcygeus fascia for repair of vaginal vault prolapse provides excellent long-term results. Critical to the success of vaginal vault suspension are adequate dissection and repair of all fascial defects. Adequate repair of the perineal body also plays a pivotal role. The anterior vaginal wall remains susceptible to recurrence.

Gestational age correlates with immunosuppressive properties of hydatidiform mole pregnancies.

PROBLEM: Soluble trophoblast extracts (HME) from some human hydatidiform mole pregnancies suppress IL-2-dependent T-cell proliferation, while others express no immunosuppressive bioactivity. This study was designed to determine if suppression by HME was correlated with gestational age, uterine size, or hCG secretion. METHOD: Soluble extracts were prepared from nine hydatidiform mole trophoblast samples and screened for immunosuppressive activity using a murine cytotoxic T-cell proliferation assay (CTLL-2). Gestational ages were determined from last menstrual cycle and uterine size was estimated at the time of surgery. Serum samples were collected prior to uterine evacuation and were assayed for human chorionic gonadotropin (hCG). RESULTS: Four of nine HME samples significantly (P < 0.05) suppressed CTLL2 proliferation, while five exhibited no suppressive activity. A strong positive correlation (r = 0.639) was noted for the relationship between gestational age of the molar pregnancies and interleukin-2 (IL-2)-stimulated CTLL2 proliferation (expressed as % of control) in the presence of HME (500 micrograms/mL). This indicates that HME suppression of CTLL2 proliferation is highest in early gestation and then declines with increasing gestational age. A similar correlation was observed between estimated uterine size at surgery and CTLL2 proliferation with added HME, although the association was not as strong (r = 0.359). No association was noted between hCG levels and CTLL2 proliferative responses (r = -0.091). CONCLUSIONS: The results of this study suggest that production of immunosuppressive factors by hydatidiform mole trophoblast is developmentally regulated, and decreases with advancing gestation.

Hydatidiform mole pregnancy trophoblast extracts differentially suppress interleukin-2-induced proliferation of human T-lymphocytes and PHA-blasts.

Immunoregulatory factors of trophoblast origin may partially abrogate maternal immune responses to the fetus during pregnancy. We have previously shown that soluble factors extracted from hydatidiform mole trophoblast suppress interleukin-2 (IL-2)-dependent proliferation of a cloned murine cytotoxic T cell line (CTLL-2). To characterize human T cell responses to this trophoblast extract, we measured the effects of molar tissue extracts (HME) on IL-2-stimulated proliferation of human T-lymphocytes and mitogen (PHA) transformed T-cell blasts (PHA-blasts). HME significantly (P less than 0.05) suppressed T-lymphocyte proliferation in response to 5 and 10 units/ml of IL-2 at 500 and 250 micrograms/ml, while no effect was observed at the 100 micrograms/ml concentration. Suppression by HME of IL-2-stimulated T-cell proliferation was partially overcome by the addition of excess IL-2. HME also suppressed (P less than 0.05) IL-2-stimulated proliferation of PHA-blasts at 500 and 250 micrograms/well at both 5 and 10 units/ml of IL-2. As observed with resting T-cell responses, no suppression of PHA-blast proliferation was observed using 100 micrograms/ml of HME. In contrast to the response of the resting T-cells to excess IL-2, HME suppression of IL-2-stimulated blast proliferation was not affected by increasing the concentration of IL-2. These results indicate that extracts from hydatidiform mole trophoblast contain immunosuppressive factors that block human T-cell clonal expansion by inhibiting the utilization and/or production of IL-2. Furthermore, the effects of HME are not reversed by excess IL-2 when PHA-blasts are reacted compared to resting T-cell responses, which are partially reversed in the presence of excess IL-2.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical practices of past graduates from one obstetric/gynecologic training program.

BACKGROUND: We sought to assess the practice patterns of former obstetric-gynecologic residents and to solicit their opinions regarding their educational experience and its clinical relevance to primary care. METHOD: In response to a Residency Review Committee mandate regarding past residents, a questionnaire was sent to all graduates from our residency program over a 17-year period (1979 to 1995). RESULTS: Of the 90 subjects who received the survey, 86 responded. Their ages ranged from 29 years to 49 years; 79 were married and 7 were single. Of the 75 in clinical practice, 71 practiced both obstetrics and gynecology and 13 had subspecialized. Most of the respondents (77/80) practiced in the mid-South. Of all graduates, 93% routinely provided primary care. In rating 20 major resident education categories, respondents gave high grades to training in surgically related areas. Only 4% rated their experience as fair or poor in the operative categories. CONCLUSION: Our graduates indicate satisfaction with their training, and their practices include primary care.

Formal pathology rotation during obstetrics and gynecology residency: is it beneficial?

BACKGROUND: Our objective was to assess the educational benefits of a formal pathology rotation during an obstetrics and gynecology residency program and to determine the utility of this information in clinical practice. METHODS: In this descriptive study, the benefits of a 2-month rotation in pathology for obstetrics and gynecology residents were analyzed. A computerized listing of surgical cases processed by each resident was sent to the obstetrics and gynecology program director. RESULTS: Our resident accessioned 5.4% of the total pathology cases processed each month. Reports from previous residents (over a 17-year period) and from program directors at the annual educational retreat indicate that such information was not relevant to our graduates in their clinical practice. CONCLUSIONS: A formal pathology rotation for obstetric residents can improve knowledge base, but the usefulness of this knowledge in clinical practice is dubious.

Sexual complications of cancer treatment.

The most common sexual dysfunctions in men are erectile impotence, retrograde ejaculation, infertility and loss of libido. Infertility is a function of the drugs and the dosage employed. Alkylating agents are likely to cause prolonged azoospermia. Sexual complications in women include stenosis and atrophy of the vagina, menstrual irregularities, early menopause and decreased libido.

Evaluation of the B-protein assay in cancer management.

Previous data have suggested that the B-protein assay might prove to be useful in the assessment of patients with cancer after various therapeutic modalities. The assay's effectiveness was evaluated by prospective study of 133 patients with cervical, uterine, or ovarian cancer. After therapy, B-protein levels remained elevated in 17 nonresponding patients who eventually died of the disease. In contrast, 88 patients experienced a significant reduction in B-protein levels measured 90 days after treatment. Among this group, 25 patients demonstrated elevated B-protein levels during the 2-year follow-up period and all were confirmed to have persistent or recurrent disease. These data indicate that monitoring serum B-protein levels can be beneficial in the posttherapeutic management of gynecologic malignancies.