A computerized tomographic evaluation of malignancies of the bladder and prostate.

Twenty cases of malignancies of the bladder and prostate were evaluated by computed tomography. This study was performed in a community hospital adjacent to a large retirement community in Southern California. Although the series was small, the results indicate that, for example, staging of carcinoma of the bladder malignancy beyond Jewitt-Marshall A can be accomplished with some ease using this modality. The extensive malignancies are easily demonstrated and their extents, in relationship to surrounding pelvic structures, are seen with considerable clarity. The use in radiation treatment planning is obvious.

Stage 3B adenocarcinoma of the endometrium: a clinicopathologic study.

OBJECTIVE: The aims of this study were to evaluate the management of Stage IIIB adenocarcinoma of the endometrium (EAC) and to determine the utility of the FIGO classification as it applies to patients with this category of disease and make recommendations on management. METHODS: A retrospective review was undertaken of the database of the Queensland Centre for Gynaecological Cancer (QCGC) from January 1982 to December 1996. The records of all patients recorded as having Stage IIIB EAC were retrieved. After validation of the designated staging, the contemporary disease status was determined and clinicopathological details were extracted from case notes. RESULTS: Of a total of 1940 patients with EAC treated by QCGC over the 15-year study period, 14 (0.7%) patients met the inclusion criteria. Nine patients (64%) presented with postmenopausal bleeding and the remaining patients presented with a variety of symptoms. There was no statistically significant difference in age between the study group and other patients with advanced stage EAC ranging from Stage IIIA to Stage IVB disease. Survival of patients with Stage IIIB disease was statistically significantly worse than that of patients with Stage IIIA disease, but was not statistically significantly different from patients with Stage IIIC, IVA, or IVB. While all patients had the unifying characteristic of metastatic disease in the vagina, the true extent of disease could not be determined by a full surgical staging procedure. Such optimal surgery was contraindicated in all patients because of the presence of significant coexisting medical conditions. Consequently, treatment was highly individualized. CONCLUSIONS: Stage IIIB adenocarcinoma of the endometrium is an uncommon condition. Similar to other substages of advanced disease, it is associated with a poor prognosis and requires individualized management. The argument is presented that this substage could be eliminated and included with Stage IIIC disease.

Patient preference the leading indication for elective Caesarean section in public patients--results of a 2-year prospective audit in a teaching hospital.

In response to a Western Australian Ministerial enquiry into the levels of intervention in childbirth, a 2-year prospective audit was undertaken of the indication and timing of all public Caesarean section deliveries at King Edward Memorial hospital. During the study period, a total of 9,138 deliveries were performed at the hospital, of which 1,624 were by Caesarean section, an overall rate of 17.8%. Of these, 633 (39%) were elective and 911 (61%) were nonelective. The most common primary indication for elective Caesarean section was maternal choice, largely due to a refusal of the patient to consent to a trial of scar following a single previous Caesarean section or a refusal to attempt a trial of vaginal breech delivery. The most common indications for nonelective Caesarean section birth were an intrapartum diagnosis of suspected fetal distress or failure to progress in labour. Strategies to reduce the incidence of Caesarean section birth need to focus on the pathways involved with maternal decision-making in the birth process, and on improving the diagnosis of intrapartum fetal compromise.

Accuracy of frozen section for the operative management of endometrial cancer.

OBJECTIVE: To assess the accuracy of intra-operative frozen section reports at identifying the features of high risk uterine disease compared with final histopathology. DESIGN: Retrospective study. METHODS: The records of 460 patients with uterine cancer registered with the Queensland Centre for Gynaecological Cancer between January 1, 1996 and December 31, 1998 were reviewed. Intra-operative frozen section was undertaken in 260 patients with endometrial adenocarcinoma. Frozen section pathology was compared with the final histopathology reports. Inter-observer reliability was assessed using percentage agreement and kappa statistics. Clinical notes were also reviewed to determine if errors resulted in sub-optimal patient care. RESULTS: Respectively, tumour grade and depth of myometrial invasion were accurately reported in 88.6% of cases (expected 61.5%, Kappa 0.70) and 94.7% (expected 53.8%, Kappa 0.89). Errors were predominantly attributable to difficulties with respect to the interpretation of tumour grade. The error resulted in the patient receiving sub-optimal surgical management in only 11 cases (5.3%) CONCLUSION: Frozen section is accurate at identifying the features of high risk uterine disease in the setting of endometrial cancer and can play an important role in directing primary operative management.

High prevalence of chlamydia and Pap-smear abnormalities in pregnant adolescents warrants routine screening.

A prospective cohort of pregnant adolescent patients who planned to deliver at 1 of 3 Perth metropolitan hospitals was studied; 1 subgroup of this cohort was offered universal screening for cervical chlamydial infection and Pap-smear abnormalities (screened), and the remainder of the cohort were offered screening at the discretion of the attending medical staff (control). High prevalences of both chlamydial infection (27%) and Pap-smear abnormalities (38%) were detected in the screened cohort. The majority of Pap-smear abnormalities were inflammatory atypia, but high-grade Bethesda lesions were also diagnosed. In the control group, the prevalence of positive swabs and abnormal Pap-smear reports in those tested was also high (22% and 35% respectively), but significantly fewer patients were tested (18% and 33% respectively in the control group, compared to 92% and 94% in the screened group; both p<0.001). Screening and treatment of chlamydia was associated with a significant decrease in the incidence of newborn febrile morbidity (10% versus 25%; p=0.02). In view of the high prevalence of positive results, it is cost-effective to offer universal screening in this setting. Failure to introduce a specific screening policy can result in a significant number of patients being denied the advantages of diagnosis and treatment.

PIP: The feasibility of routine screening for cervical chlamydial infection and Pap smear abnormalities was assessed in a comparative study conducted among pregnant adolescents 17 years or younger at three hospitals in Perth, Western Australia, during 1997-98. 100 women were offered universal screening for chlamydia and Pap smears; 60 controls received screening only at the discretion of the attending medical staff. High prevalence of both chlamydia (27%) and Pap smear abnormalities (38%) was observed in the screened group. The majority of Pap smear abnormalities were inflammatory atypia. 18% of controls were tested for chlamydia and 33% received Pap smears; the prevalence of positive swabs and abnormal smears was 22% and 35%, respectively. Screening and treatment of chlamydia was associated with a significant decrease in the incidence of newborn febrile morbidity among women in the universal screening group compared with controls (10% vs. 25%, p = 0.02). In view of the high prevalence of positive results in this study, universal screening is recommended for pregnant adolescents.

Adolescent pregnancy: psychopathology missed.

OBJECTIVES: Few data exist that explore the level of psychosocial problems and drug abuse in an Australian, adolescent, antenatal population. We set out to audit these data from a population of pregnant Western Australian adolescents. We also set out to examine whether social issues and the use of non-prescription drugs are routinely addressed in general public antenatal clinics. METHODS: One hundred and sixty patients were involved in the prospective cohort study. In the assessed group, 100 consecutive patients from the King Edward Memorial Hospital Adolescent Antenatal Clinic were interviewed during the antenatal period to determine if any major psychosocial issues or a history of non-prescription drug abuse was present. The control group consisted of 60 adolescent patients who delivered in general antenatal clinics at three Perth metropolitan hospitals. RESULTS: Sixty percent of the assessed group were identified as having a major psychosocial problem that interfered with their ability to carry out acts of daily living. Consumption of cigarettes, alcohol, marijuana, heroin and solvents were higher than that reported for the general Australian adolescent population. Of note, in the control group, many patients did not have a social, psychological, or drug use history taken by their caregivers. CONCLUSION: Failure to identify psychosocial problems and drug abuse during the antenatal period will result in missed opportunities for positive intervention. These problems are common in this population and interventions are required to offer these women alternative foundations upon which to base their mothercraft skills.

Endometrial adenocarcinoma--presenting pathology is a poor guide to surgical management.

We aimed to evaluate the correlation between the histological grade of endometrial cancer diagnosed on endometrial biopsy or curettage, with the definitive grade and stage of lesion as determined by surgery and histopathological examination and to make recommendations about the suitability of conservative surgery based on pre-operative determination of the grade of endometrial adenocarcinoma. A retrospective review of all patients with endometrial adenocarcinoma presenting to the Queensland Centre for Gynaecological Cancer from 1 January 1996 to 31 December 1998 was undertaken. Clinical and pathological data was abstracted from medical records and case notes of 460 patients. All histological specimens were prospectively reviewed by a panel consisting of gynaecologic pathologists, gynaecologic oncologists and other doctors involved in the treatment of patients with gynaecological malignancies. The percentage of patients whose management would have been optimised by full surgical staging at the time of initial surgery was calculated. Only 60%, 71%, and 84 % of the patients with a presenting diagnosis of grade 1, 2 and 3 endometrial adenocarcinomas respectively had this confirmed on final histopathology. Furthermore, using established criteria, 30%, 46% and 100% of patients presenting with grade 1, 2 and 3 endometrial adenocarcinoma required full surgical staging at the time of their primary surgery There is poor correlation between the pre-operative grade of endometrial cancer and the grade as determined on analysis of the resected uterus. The correlation is poorest with grade 1 endometrial adenocarcinoma, where strongest consideration is given to conservative surgery and the avoidance of subspecialty referral. There is a strong argument that all patients with a diagnosis of endometrial cancer made on endometrial biopsy or curettage, regardless of grade of malignancy, should be offered surgery where the option to perform concurrent comprehensive surgical staging is available.