The E3 ubiquitin ligase EDD is an adverse prognostic factor for serous epithelial ovarian cancer and modulates cisplatin resistance in vitro.

Despite a high initial response rate to first-line platinum/paclitaxel chemotherapy, most women with epithelial ovarian cancer relapse with recurrent disease that becomes refractory to further cytotoxic treatment. We have previously shown that the E3 ubiquitin ligase, EDD, a regulator of DNA damage responses, is amplified and overexpressed in serous ovarian carcinoma. Given that DNA damage pathways are linked to platinum resistance, the aim of this study was to determine if EDD expression was associated with disease recurrence and platinum sensitivity in serous ovarian cancer. High nuclear EDD expression, as determined by immunohistochemistry in a cohort of 151 women with serous ovarian carcinoma, was associated with an approximately two-fold increased risk of disease recurrence and death in patients who initially responded to first-line chemotherapy, independently of disease stage and suboptimal debulking. Although EDD expression was not directly correlated with relative cisplatin sensitivity of ovarian cancer cell lines, sensitivity to cisplatin was partially restored in platinum-resistant A2780-cp70 ovarian cancer cells following siRNA-mediated knockdown of EDD expression. These results identify EDD as a new independent prognostic marker for outcome in serous ovarian cancer, and suggest that pathways involving EDD, including DNA damage responses, may represent new therapeutic targets for chemoresistant ovarian cancer.

A distinct molecular profile associated with mucinous epithelial ovarian cancer.

Mucinous epithelial ovarian cancers (MOC) are clinically and morphologically distinct from the other histological subtypes of ovarian cancer. To determine the genetic basis of MOC and to identify potential tumour markers, gene expression profiling of 49 primary ovarian cancers of different histological subtypes was performed using a customised oligonucleotide microarray containing >59 000 probesets. The results show that MOC express a genetic profile that both differs and overlaps with other subtypes of epithelial ovarian cancer. Concordant with its histological phenotype, MOC express genes characteristic of mucinous carcinomas of varying epithelial origin, including intestinal carcinomas. Differences in gene expression between MOC and other histological subtypes of ovarian cancer were confirmed by RT-PCR and/or immunohistochemistry. In particular, galectin 4 (LGALS4) was highly and specifically expressed in MOC, but expressed at lower levels in benign mucinous cysts and borderline (atypical proliferative) tumours, supporting a malignant progression model of MOC. Hence LGALS4 may have application as an early and differential diagnostic marker of MOC.

Genetic aberrations detected by comparative genomic hybridisation in vulvar cancers.

Squamous cell carcinoma of the vulva is a disease of significant clinical importance, which arises in the presence or absence of human papillomavirus. We used comparative genomic hybridisation to document non-random chromosomal gains and losses within human papillomavirus positive and negative vulvar cancers. Gain of 3q was significantly more common in human papillomavirus-positive cancers compared to human papillomavirus-negative cancers. The smallest area of gain was 3q22-25, a chromosome region which is frequently gained in other human papillomavirus-related cancers. Chromosome 8q was more commonly gained in human papillomavirus-negative compared to human papillomavirus-positive cancers. 8q21 was the smallest region of gain, which has been identified in other, non-human papillomavirus-related cancers. Chromosome arms 3p and 11q were lost in both categories of vulvar cancer. This study has demonstrated chromosome locations important in the development of vulvar squamous cell carcinoma. Additionally, taken together with previous studies of human papillomavirus-positive cancers of other anogenital sites, the data indicate that one or more oncogenes important in the development and progression of human papillomavirus-induced carcinomas are located on 3q. The different genetic changes seen in human papillomavirus-positive and negative vulvar squamous cell carcinomas support the clinicopathological data indicating that these are different cancer types.

Progressive genetic aberrations detected by comparative genomic hybridization in squamous cell cervical cancer.

Genetic changes orchestrated by human papillomaviruses are the most important known factors in carcinogenesis of the uterine cervix. However, it is clear that additional genetic events are necessary for tumour progression. We have used comparative genomic hybridization to document non-random chromosomal gains and losses within a subset of 37 cervical carcinomas matched for clinical stage Ib, but with different lymph node status. There were significantly more chromosomal changes in the primary tumours when the lymph nodes were positive for metastases. The most frequent copy number alterations were loss of 3p, 11q, 6q and 10q and gain of 3q. The smallest areas of loss and gain on chromosome 3 were 3p14-22 and 3q24-26. The study identifies progressive DNA copy number changes associated with early-stage invasive cervical cancers with and without lymph node metastases, a factor of potential prognostic and therapeutic value.

Thin layer compared to direct smear in thyroid fine needle aspiration.

The efficacy of preparing thyroid fine needle aspirations (FNAs) by the thin layer as opposed to the direct smear method has not been evaluated sufficiently in a regional laboratory setting. At the Foothills Hospital (Calgary, Canada), the method of processing thyroid FNAs was changed from direct smear to thin layer in January 1996. The results of 327 patients who had direct smear from 1994 to 1995 were compared to 401 who had thin layer between 1996 and 1997. While there were no significant differences across a broad range of quality indicators, thin layer showed a trend towards a higher proportion of true benign diagnoses (31% vs 24%), a lower proportion of inadequate specimens (41% vs 50%) and, most importantly, a lower false negative rate (3% vs 9%). In conclusion, the changeover to thin layer did not compromise the interpretation of thyroid FNAs.

Vulvar squamous cell carcinoma and lichen sclerosus.

There are two clinicopathological types of vulvar squamous cell carcinoma, human papillomavirus (HPV)-positive and HPV-negative, which can be distinguished to some degree on routine histology. Human papillomavirus-positive carcinomas account for one-quarter to one-third of cases, occur in women on average 20 years younger than in HPV-negative, and are associated with multiple lower genital tract neoplasia. Human papillomavirus negative carcinoma is linked to lichen sclerosus. Of all carcinomas, 7-96% show lichen sclerosus in skin adjacent to the carcinoma, the majority being the first presentation of lichen sclerosus, and up to 5% of patients with lichen sclerosus develop carcinoma after long-term follow up. Where lichen sclerosus is associated with malignancy, it is often hyperplastic, may show a subtle form of intraepithelial neoplasia termed 'differentiated vulvar intraepithelial neoplasia', and may lose its pathognomonic oedematous-hyaline layer. The local additional factors causing lichen sclerosus to develop malignancy on the vulva are not known.

Candida glabrata chorioamnionitis following in vitro fertilization and embryo transfer.

Candida glabrata is a yeast which is considered to be a commensal of the vagina with limited pathogenicity in the immunocompetent host. We report 2 cases of severe chorioamnionitis occurring in pregnancies achieved by in vitro fertilization techniques which resulted in preterm delivery and pregnancy loss. Candida glabrata as the causative agent was probably introduced into the uterus by the cannula at the time of embryo transfer. It is recommended that appropriate investigation of the microbial flora of the cervix be undertaken and treatment instituted prior to embryo transfer in order to prevent this complication.

Combined ovarian serous papillary and hepatoid carcinoma.

Hepatoid carcinoma is a rare type of malignant tumor resembling hepatocellular carcinoma that arises in extrahepatic sites. A case of a combined hepatoid and serous papillary carcinoma of the ovary in a 72-year-old woman is reported. The hepatoid component showed alpha-fetoprotein production. Imperceptible merging of the hepatoid and serous papillary components was seen, supporting the theory of a surface epithelial origin of ovarian hepatoid carcinoma.

Alpha-fetoprotein production by a malignant mixed müllerian tumour of the uterus.

A case of alpha-fetoprotein production by a uterine malignant mixed müllerian tumour is described. The patient was a 68 year old woman who developed intraabdominal recurrence of a stage 1 uterine tumour which had been treated surgically seven years previously. Her serum alpha-fetoprotein was raised at 21,000 micrograms/l (normal < 10 micrograms/l) and staining with immunoperoxidase confirmed that the tumour was the site of alpha-fetoprotein production. The patient was treated with combination chemotherapy but died two weeks after the first course. This is believed to be only the second such case reported.

Cytology in the follow-up of cervical cancer.

OBJECTIVE: To determine the value of cytology in the follow-up of cervical cancer. STUDY DESIGN: The study group consisted of 230 patients with invasive cervical carcinoma who were followed for one to seven years. Forty-four patients developed recurrences or metastases. During this period, cytologic investigations involved 795 exfoliative smears from the cervix or vaginal vault, 10 fine needle aspirates and 5 fluids. RESULTS: Thirty-three patients had positive or inconclusive cervical or vault smears that were histologically proven to be recurrences, and the other 11 patients had clinically obvious recurrences that were not smeared. Cytology first alerted the clinicians to recurrence in eight patients. Of 25 cervical or vault smears reported as malignant, 24 (96%) were histologically confirmed, and 1 showed radiation change on biopsy. In all 22 cases of smears reported as inconclusive, a biopsy followed, and in 9 (41%) of these, recurrence was demonstrated histologically. Inability to distinguish radiation change from recurrent malignancy was the chief cause of inconclusive smears. Five fluids and seven fine needle aspirates were diagnosed as malignant, saving patients an invasive diagnostic procedure. CONCLUSION: Cytology is a useful, cost-effective, noninvasive and accurate investigation in the follow-up of cervical cancer.

Evaluation of patch testing in patients with chronic vulvar symptoms.

The Dermogynaecology Clinic was established at the Mercy Hospital for Women in 1989. Since its inception, 700 patients have been investigated and 15% were clinically diagnosed as having contact dermatitis. Primary irritant dermatitis was regarded as the common cause but to investigate the place of contact allergy 50 patients were patch tested to a standard battery, medicaments, preservatives, corticosteroids and miscellaneous allergens. Twenty-one patients (42%) had a total of 44 positive tests. The most common positive reactions were to nickel (22%), cobalt (6%), fragrances (12%), caine mix (6%) and ethylenediamine (8%). Medicaments and fragrances were regarded as important allergens. Corticosteroid and imidazole allergy was not a problem in this series of patients.

Invasive cervical cancer in pregnancy.

Cervical cancer is the commonest malignancy which complicates pregnancy, but the management remains controversial. We reviewed our patients in an attempt to identify the best management options which resulted in long-term survival for the mother and a live baby. The total number of pregnancies managed between January, 1981 and March, 1995 was obtained from the hospital records, and patients with invasive cervical cancer diagnosed during pregnancy or within 12 months of delivery were identified. The case records were reviewed. Between January, 1981 and March, 1995 there were 22 cases of cervical cancer diagnosed either during pregnancy or within 12 months postpartum. This gave an incidence of cervical cancer associated with pregnancy of 1 in 3,817 pregnancies or 0.26 per 1,000 pregnancies. Eleven patients had microinvasive disease. Nine were treated by cone biopsy and 2 by radical hysterectomy. Nine patients had Stage 1B and 1 had Stage 2A disease and all were treated with radical hysterectomy. One patient had Stage 3B disease and was treated with radiotherapy and chemotherapy followed by simple hysterectomy. Fourteen patients delivered vaginally. Twenty of the 22 patients were delivered of live babies which survived. The patients have been followed from 1 month to 13 years with only 1 recurrence, and all 22 remain alive. We conclude that all pregnant women should have a Pap smear performed antenatally. Cone biopsy can be safely performed in pregnancy and may be adequate treatment for microinvasive squamous cell carcinomas. Treatment, including the timing of delivery, must be individualized, with the patient playing an important decision-making role.

Audit of 114 non-neoplastic vulvar biopsies.

OBJECTIVE: The purpose of this study was to show the benefits and limitations of vulvar biopsy in the setting of a multidisciplinary clinic specialising in non-neoplastic diseases of the vagina and vulva. DESIGN: One hundred and fourteen vulvar biopsies were reviewed and classified according to the classification of the International Society for the Study of Vulvar Diseases. RESULTS: The histological diagnoses were lichen sclerosus 25%, lichen simplex chronicus 35%, non-erosive inflammatory dermatoses comprising psoriasis, spongiotic dermatitis, dermatophytosis and psoriasiform dermatitis 13%, erosive vulvitis and lichen planus 9%, nonspecific inflammation 6%, miscellaneous 9% and normal 4%. CONCLUSIONS: Biopsies in cases of lichen sclerosus were useful for confirmation of clinical diagnosis and to exclude early invasive malignancy. In lichen simplex chronicus, biopsies helped exclude an underlying dermatosis requiring specific treatment. Psoriasis, spongiotic dermatitis, dermatophytosis and excoriated lichen simplex chronicus posed a common clinical differential diagnosis of the reddened vulva. The eroded vulva often proved a diagnostic problem clinically and histologically. The clinical syndrome of vestibulitis did not have a specific histological picture, and biopsies showed nonspecific inflammation, mild hyperplasia or were normal. No case of squamous cell hyperplasia was diagnosed and the place of this diagnosis in the ISSVD classification needs review.

Grapelike leiomyoma of the uterus.

A 24-year-old nulliparous woman underwent laparotomy for a large pelvic mass. Grapelike tumor extending from the uterus into the broad ligaments and peritoneal cavity was found. A diagnosis of sarcoma appeared likely, but radical surgery was avoided when frozen sections indicated a histologically benign smooth muscle tumor.

In situ hybridization of parathyroid hormone-related protein in normal skin, skin tumors, and gynecological cancers using digoxigenin-labeled probes and antibody enhancement.

We describe a novel procedure for in situ hybridization that combines the use of digoxigenin-labeled oligonucleotide probes with an antibody enhancement step that can be performed on formalin-fixed, paraffin-embedded tissues. Addition of a second antibody enhances the visibility of parathyroid hormone-related protein (PTHrP) mRNA expression from barely to highly discernible and interpretable, with virtually no nonspecific background expression. This technique has allowed visualization of PTHrP mRNA in normal human skin and epithelium-derived tumors. PTHrP mRNA expression was confined to the basal and spinous keratinocyte layers of skin. There was strong hybridization in the spinous keratinocyte layer and a low level of hybridization in the basal layer. An extensive panel of positive and negative controls included poly d(T) probe to indicate total mRNA present in the sections. Squamous cell carcinomas and basal cell carcinomas of the skin, from pathology archives, were examined for the presence of PTHrP mRNA. The results reflected previous immunohistochemical studies, with every squamous cell carcinoma hybridizing strongly with the PTHrP probes. The basal cell carcinomas showed no expression of PTHrP mRNA, although the total mRNA signal was very strong. The localization of PTHrP mRNA in the tumors of the gynecological tract also reflected the immunohistochemical findings, with expression found in the squamous cell carcinomas but not in the adenocarcinomas. In situ hybridization with digoxigenin-labeled oligonucleotide probes and antibody enhancement has provided a sensitive, highly specific procedure for detection of PTHrP mRNA in tumors and normal tissue.

Human papillomavirus vulvitis: a new disease or an unfortunate mistake?

OBJECTIVE: To determine whether human papillomavirus (HPV) was responsible for symptoms in women with vulvar pruritus, pain and superficial dyspareunia who had been referred with a diagnosis of HPV vulvar disease made on clinical and/or colposcopic and/or histological grounds. DESIGN: In addition to standard clinical and laboratory investigations of the whole population, a sample of 15 test cases from the population of 71 women referred with a clinicopathological diagnosis of HPV vulvar disease, and two positive and 21 negative controls were assayed for HPV DNA. Polymerase chain reaction assays using L1 consensus primers were performed blinded to the clinicopathological diagnosis. SETTING: Dermogynaecology Clinic at Mercy Hospital for Women. SUBJECTS: Seventy-one women referred with a diagnosis of HPV vulvar disease. RESULTS: Thirteen cases which could be tested for HPV DNA were negative. Diagnoses other than HPV were found for the women's presentation in all cases. CONCLUSIONS: In the population studied, our investigations indicated that the clinicopathological diagnosis of HPV infection was incorrect and that HPV was not a cause of vulvar symptoms. We believe that the term HPV vulvitis is unfortunate as it has invited destructive treatments and drawn attention away from more likely causes of this difficult group of vulvar conditions.

Hydrocephalus ex vacuo and clasp thumb deformity due to congenital cytomegalovirus infection.

A case of congenital hydrocephalus in a male infant with flexion deformity of the thumbs and great toes is reported. A maternal uncle had undefined intellectual impairment and X-linked hydrocephalus was considered among the differential diagnoses. However, this diagnosis was considered unlikely as the pyramids were preserved at autopsy. In addition, postmortem histopathology and viral culture established cytomegalovirus (CMV) infection as the underlying cause of the hydrocephalus. Although CMV infection is a well recognized cause of congenital hydrocephalus, the associated flexion deformities of the thumbs and great toes have not been previously described and may reflect injury to the corticospinal tracts.

Extrauterine malignant mixed müllerian tumor of primary peritoneal origin.

The case of an extrauterine heterologous malignant mixed müllerian tumor (MMMT) of primary peritoneal origin occurring in a 63 yr old woman is presented. The tumor was a 19 cm, soft, friable mass arising from the serosa of the sigmoid colon and spreading to adjacent pelvic peritoneum. The uterus, tubes and ovaries were uninvolved. It was composed of sarcomatous areas showing cartilaginous and rhabdomyoblastic differentiation and sharply demarcated carcinomatous areas showing endometrioid and serous differentiation. This is the thirteenth reported case of an extragenital MMMT. It demonstrates the pluripotentiality of female pelvic peritoneum to differentiate into tumors resembling those of the genital tract.

Immunoreactivity of antibodies to epidermal growth factor, transforming growth factors alpha and beta, and epidermal growth factor receptor in the premenopausal ovary.

This study provides a valuable insight into the localization of growth factors in paraffin sections of human ovarian tissue. Antibodies to epidermal growth factor (EGF), transforming growth factors alpha and beta (TGF alpha and beta) and epidermal growth factor receptor (EGFR) were applied to paraffin sections of 16 cases of formalin-fixed normal or benignly abnormal ovarian tissue. All growth factor antibodies reacted with theca, but not granulosa cells, whilst the antibody to EGFR reacted with both types of follicular cells and was weakly reactive in ovarian stroma. There were no discernible qualitative changes in reactivity during the follicular cycle. These immunohistochemical findings generally support previously published molecular and biochemical data from tissue culture. One exception is in the observation of immunoreactivity to EGF in theca and granulosa cells. This may be due to differences in sensitivity of the methods in use. The possibility of a cross-reaction of the anti-EGF antibody with TGF alpha is also discussed. This study provides evidence for both paracrine and autocrine roles for growth factors in folliculogenesis.

Parathyroid hormone-related protein and human papillomavirus in gynecological tumors.

The presence of parathyroid hormone-related protein (PTHrP) and human papillomavirus (HPV) in a series of gynecological tumors from 131 unselected patients was examined. PTHrP was localized immunohistochemically using a highly specific rabbit polyclonal anti-serum against PTHrP(1-16). The results confirmed that gynecological malignancies, although rarely associated with humoral hypercalcemia of malignancy (HHM), stained for PTHrP in a majority of the squamous-cell carcinomas (SCC) at all sites, but only in a minority of adenocarcinomas, and then in areas of squamous metaplasia. This included a series of endometrial tumors. Detection of HPV types was achieved using a polymerase-chain-reaction (PCR) detection system enabling the detection of HPV types 6, 11, 16, 18, 31, 33 and 45. PTHrP production was not directly related to HPV infection, but correlated with the type of tumor.