Evaluation of atypical glandular cells of undetermined significance: is age important?

OBJECTIVE: Our purpose was to assess the effect of age on the incidence of significant pathologic findings in patients with atypical glandular cells of undetermined significance. STUDY DESIGN: This retrospective study evaluated nonreferred patients with Papanicolaou smears showing atypical glandular cells of undetermined significance over a 5-year period. RESULTS: Two hundred eighty-one women (91%) with Papanicolaou smears showing atypical glandular cells of undetermined significance were available for follow-up. Significant abnormality was found in 90 subjects (32%), including 31 women (11%) with cancer. Older patients (> or =50 years old) have lower odds of high-grade cervical dysplasia (odds ratio = 0.21; 95% CI: 0.32-0.40) and higher odds of uterine cancer (odds ratio = 12.88; 95% CI: 1.78-567.60) compared with younger patients. CONCLUSIONS: Women with Papanicolaou smears showing atypical glandular cells of undetermined significance have a 1 in 3 chance of having significant abnormality. Evaluation includes colposcopy, endocervical curettage, and appropriate cervical biopsies. Patients >45 years require endometrial biopsies.

Low birth weight and preeclampsia in pregnancies complicated by hyperthyroidism.

OBJECTIVE: To determine whether control of hyperthyroidism during pregnancy reduces the risk of low birth weight infants and severe preeclampsia. METHODS: Labor, delivery, and postpartum records of 181 hyperthyroid women were reviewed for maternal and fetal outcomes. Subjects were separated into three groups based on their thyroid status: controlled (n = 34), including women who were euthyroid at presentation and delivery; controlled during pregnancy (n = 90), including women who were hyperthyroid at presentation and euthyroid at delivery; and uncontrolled (n = 57), including women who were hyperthyroid at presentation and delivery. RESULTS: The risk of low birth weight infants was 0.74 (95% confidence interval [CI] 0.18-3.08) among controlled women, 2.36 (95% CI 1.36-4.12) among women who were controlled during pregnancy, and 9.24 (95% CI 5.47-15.6) among women who were uncontrolled during pregnancy compared to the incidence among nonhyperthyroid mothers. The risk of severe preeclampsia was significantly higher (odds ratio 4.74, 95% CI 1.14-19.7) among uncontrolled women compared with those who were controlled during their pregnancies. Elevated TSH-receptor antibody levels were not related to preeclampsia. Maternal thioamide therapy did not adversely affect neonatal outcomes. CONCLUSION: Lack of control of hyperthyroidism significantly increases the risk of low birth weight infants and severe preeclampsia.

The process of carcinogenesis for endometrial adenocarcinoma could be short: development of a malignancy after endometrial ablation.

Endometrial ablation has been proposed as an alternative to hysterectomy for the treatment of dysfunctional uterine bleeding. We describe what we believe to be the first reported case of an endometrial adenocarcinoma that may have developed shortly after endometrial ablation.

Long-term experience with a totally implanted catheter system in gynecologic oncologic patients.

A significant number of gynecologic oncologic patients require intravenous chemotherapy. Peripheral venous access frequently becomes difficult, necessitating reliable central venous access. This study was done to retrospectively review our experience with completely implanted venous access ports (ports). There were 100 women from 1984 to 1992 who received 115 ports. These ports remained in situ on average 350 +/- 2.3 days for a total of 110 patient years; 38 ports were in place for more than one year. An average of six courses of chemotherapy were given through each port. There was no statistically significant difference demonstrated in the complication rate secondary to site or side of placement (p = 0.5). Catheter performance in 77 percent of the patients was impeccable. We conclude that implantable ports are a safe and reliable method of chronic venous access in gynecologic oncologic patients requiring intravenous chemotherapy. Although ports reduce the number of complications and manipulations associated with percutaneous catheters, they are not devoid of problems.

A comparison of propylthiouracil versus methimazole in the treatment of hyperthyroidism in pregnancy.

OBJECTIVE: Our purpose was to demonstrate that propylthiouracil and methimazole are equally effective and safe in the treatment of hyperthyroidism during pregnancy. STUDY DESIGN: Between 1974 and 1990 records were available on 185 pregnant patients with a history or diagnosis of hyperthyroidism. Ninety-nine patients were treated with propylthiouracil and 36 with methimazole. The response to therapy was compared with respect to the time to normalization of the free thyroxine index and the incidences of congenital anomalies and hypothyroidism. RESULTS: The time to normalization of the free thyroxine index was compared in the two groups by means of survival analysis. The median time to normalization of the free thyroxine index on propylthiouracil and methimazole was 7 and 8 weeks, respectively (p = 0.34, log-rank test). The incidence of major congenital malformations in mothers treated with propylthiouracil and methimazole was 3.0% and 2.7%, respectively. No neonatal scalp defects were seen. One infant was overtly hypothyroid at delivery. CONCLUSION: Propylthiouracil and methimazole are equally effective and safe in the treatment of hyperthyroidism in pregnancy.

CA-125: a marker for persistent gestational trophoblastic disease?

The objective was to determine whether CA-125 levels have any clinical utility in gestational trophoblastic disease. Fifty-one patients with a pathologically confirmed diagnosis of complete hydatidiform mole had a CA-125 level obtained prior to suction molar evacuation. Data were analyzed using chi 2 and Mann-Whitney U test. CA-125 levels were twice as high in persistent gestational trophoblastic disease than those in complete hydatidiform molar patients (85.9 vs 48.3 U/ml; P = 0.004). CA-125 levels were independent of age, gravidity, weeks of amenorrhea, or presence of thecal-luteal cysts. CA-125 levels appear to be of value in predicting which molar patients will develop persistent disease.

Neovaginal procidentia.

Split-thickness skin grafts combined with an omental pedicle is a popular method of vaginal reconstruction. An unusual case of neovaginal prolapse presenting 3 months after construction is presented. Sacral colpopexy using autogenous fascial tissue allowed for both anatomical and functional correction of this neovagina.

Preservation of ovarian tissue in adnexal torsion with fluorescein.

OBJECTIVE: Our purpose was to assess the ability of fluorescein to intraoperatively detect viable fallopian and ovarian tissues involved in adnexal torsion. STUDY DESIGN: This prospective study was performed at Los Angeles County+University of Southern California Women's Hospital. Participants were female patients 18 to 45 years old with adnexal torsion confirmed at exploratory celiotomy. Five milliliters of 10% fluorescein were injected intravenously, and the involved untwisted adnexa was observed under ultraviolet light. Nonfluorescent tissue was resected and histologically evaluated. RESULTS: Eleven patients were entered into the study. Mean age was 25 years (range 15 to 42). Eight patients (72%) had preservation of involved ovarian tissue. No complications were associated with this procedure. Only three patients (28%) underwent oophorectomy. CONCLUSION: The use of intravenous fluorescein appears to be a valuable adjunct in the management of adnexal torsion. Application of this technique in reproductive-aged patients resulted in a three-quarter reduction in oophorectomy procedures.

Perinatal outcome in hypothyroid pregnancies.

OBJECTIVE: To relate hypothyroidism to perinatal outcome. METHODS: A cohort of 68 hypothyroid patients with no other medical illnesses was divided into two groups according to the initial thyroid function tests. The first group had 23 women with overt hypothyroidism, and the second had 45 subjects with subclinical hypothyroidism. We sought to identify the pregnancy outcomes of gestational hypertension, low birth weight, fetal death, congenital anomalies, maternal anemia, and postpartum hemorrhage. RESULTS: Gestational hypertension--namely, eclampsia, preeclampsia, and pregnancy-induced hypertension--was significantly more common in the overt and subclinical hypothyroid patients than in the general population, with rates of 22, 15, and 7.6%, respectively. In addition, 36% of the overt and 25% of the subclinical hypothyroid subjects who remained hypothyroid at delivery developed gestational hypertension. Low birth weight in both overt and subclinical hypothyroid patients was secondary to premature delivery for gestational hypertension. Except for one stillbirth and one case of clubfeet, hypothyroidism was not associated with adverse fetal and neonatal outcomes. CONCLUSION: Normalization of thyroid function tests may prevent gestational hypertension and its attendant complications in hypothyroid patients.

Recurrent endometrial cancer arising in the round ligament.

An unusual case of recurrent endometrial carcinoma presenting as a round ligament metastasis is discussed. The primary lesion detected six years earlier was a well-differentiated lesion with less than 50% myometrial invasion located in the fundus. A persistent inguinal swelling represented a metastasis to the round ligament. Histologic examination revealed a poorly differentiated adenocarcinoma. Patients with early stage well-differentiated endometrial carcinoma are not immune from late recurrence.

Ureteroscopy: a new asset in the management of postoperative ureterovaginal fistulas.

Iatrogenic ureteral injury, an uncommon entity, is primarily caused by complications of gynecologic surgery. This report describes a case of ureterovaginal fistula discovered 13 days after a vaginal hysterectomy. Ureteroscopy was performed, with passage of an indwelling ureteral stent for 6 weeks. The patient immediately became continent of urine and the fistula healed, thus avoiding the need for further surgery.

A randomized clinical trial comparing the Cytobrush and cotton swab for Papanicolaou smears.

OBJECTIVE: We sought to determine whether use of the Cytobrush/spatula or the cotton swab/spatula is better in obtaining satisfactory Papanicolaou smears as defined by the Bethesda System. METHODS: This 1-year randomized trial was performed at the Los Angeles County + University of Southern California Women's Hospital colposcopy clinic. Participants were all nonpregnant patients referred to the colposcopy clinic for abnormal Papanicolaou smears. The main outcome measurement was the effectiveness in obtaining satisfactory Papanicolaou smears as defined by the Bethesda System. Data were analyzed using the Pearson chi 2 test. RESULTS: The sampling methods had similar abilities to obtain a satisfactory smear (Cytobrush/spatula 63%, cotton swab/spatula 57%; P = .23). Less-than-optimal smears accounted for 28% of the Cytobrush group and 38% of the cotton-swab group. The Cytobrush was superior in its ability to obtain endocervical cells (Cytobrush 80%, cotton swab 60%; P less than .01). Both sampling methods had similar rates of correlation with histologic diagnosis. No complications were associated with either technique. CONCLUSIONS: The Cytobrush/spatula is superior to the cotton swab/spatula in obtaining endocervical cells. There appears to be no difference in each method's ability to obtain satisfactory smears. Application of the Bethesda System results in a significant number of less-than-optimal smears using either technique.

A clinical-pathology review of cervical intraepithelial neoplasia following cryotherapy failure.

Cervical intraepithelial neoplasia (CIN) after cryotherapy can pose both diagnostic and therapeutic problems. To clarify these issues, 27 consecutive patients who underwent cone biopsy for CIN after cryotherapy over a 10-year period at Women's Hospital LAC + USC Medical Center were reviewed. Although the initial features of the cervical intraepithelial neoplasia allowed for outpatient cryotherapy, the features of these failures did not (unsatisfactory colposcopy or CIN in the endocervical curettings). Eleven percent of these patients had stromal invasion on cone biopsy that was not suspected clinically. Patients presenting with cervical intraepithelial neoplasia following cryotherapy may, in fact, have progressive disease (i.e., stromal invasion) that is inapparent clinically. Hence, surgical excision should be considered in these circumstances.

Gastrointestinal signet ring carcinoma metastatic to the cervix during pregnancy. A case report.

Extragenital carcinoma metastatic to the cervix is uncommon. In such a case a complication not previously described occurred in association with pregnancy: gastrointestinal signet ring carcinoma metastatic to the cervix. The entity was initially detected on a histologic examination of cervical biopsy specimens and was confirmed with gastric endoscopic biopsies, thereby preventing an exploratory laparotomy. The patient declined palliative chemotherapy.

Mayer-Rokitansky-Kuster-Hauser syndrome associated with endodermal sinus tumor of the ovary.

Both EST and Mayer-Rokitansky-Kuster-Hauser syndrome are uncommon disorders. This report illustrates a case of these two rare conditions occurring in the same patient. Patients with Mayer-Rokitansky-Kuster-Hauser syndrome, although not appearing to be at increased risk for germ cell tumors, unlike testicular feminization patients, are not immune to ovarian cancer. Therefore, individuals with Mayer-Rokitansky-Kuster-Hauser syndrome should still be followed gynecologically because they are at least at the normal risk of developing ovarian as well as other gynecological neoplasms.

Ifosfamide-induced neurotoxicity.

Ifosfamide is an active chemotherapeutic agent in a wide range of gynecologic tumors; favorable response rates have been reported in ovarian (epithelial and germ cell), uterine, and cervical neoplasms. Central neurotoxicity is a known, but poorly described side effect. We report 23 patients who received a total of 75 cycles of ifosfamide, either as a single agent or in combination with other chemotherapeutic agents. Six of twenty-three (26%) experienced grade 4 neurotoxicity; clinical presentation included confusion, aphasia, hallucinations, and coma. All patients exhibited the first evidence of neurotoxicity by the end of the 24-hr infusion. Three of six patients with grade 4 neurotoxicity expired within 14 days of receiving ifosfamide. The neurotoxicity resolved over 2 to 4 days in the remaining patients. Serum albumin was normal (greater than 3.5 g/dl) in 63 cycles of ifosfamide not associated with neurotoxicity. When serum albumin was less than 3.5 g/dl, 6 of 12 cycles were associated with severe neurotoxicity (P less than 0.001). Low serum albumin (less than 3.5 g/dl) appears to be associated with a high risk of severe neurotoxicity in patients receiving single-dose ifosfamide therapy.

Urethral pressure changes in women with detrusor instability. Bladder or urethral pathologic process?

One hundred and fourteen female patients had clinical and urodynamic diagnosis of detrusor instability. They all received oxybutynin chloride (Ditropan) 5 mg t.i.d. for four weeks and evaluation repeated. Sixty-six of the 114 patients (58%) responded favorably to anticholinergic treatment while 48 patients (42%) did not. Based on urethrocystometry, two groups of patients were identified: Group I consisted of 73 women with bladder contraction that preceded any change in urethral pressure. Group II consisted of 41 patients with urethral pressure drop that preceded the detrusor contraction by a few seconds. Sixty-one of the 73 women (84%) in Group I responded favorably to four weeks of anticholinergic therapy while 88 percent (36 of 41) of women in Group II did not (P less than 0.01). Our results suggest that women with bladder contraction that is preceded by urethral relaxation represent a different pathologic entity than women with "classic detrusor instability".

Ovarian neoplasms and the risk of adnexal torsion.

Previous reports examining adnexal torsion suggested that benign ovarian neoplasms are more likely to undergo torsion than malignant ovarian neoplasms. To our knowledge, this clinical observation has not been quantified. To examine this hypothesis, we reviewed our experience with ovarian neoplasms found at the time of surgery over a 10-year period. Benign ovarian neoplasms had a 12.9-fold increased risk of undergoing adnexal torsion when compared with malignant ovarian neoplasms (95% confidence interval, 10.2 to 15.9). The histologic type of ovarian neoplasm does not appear to affect the rate of adnexal torsion. Adnexal torsion rarely involves cancer.

Renal artery laceration secondary to percutaneous nephrostomy catheter placement.

Renal artery hemorrhage secondary to placement of percutaneous nephrostomy catheters can lead to major operations and even nephrectomy. We recently treated a woman who suffered a renal artery laceration during percutaneous nephrostomy catheter placement using interventional radiographic techniques. The perforation site was identified using angiography and treated using selective embolization. The patient was able to avoid a surgical procedure with its inherent risks.

The Ball-Burch procedure for stress incontinence with low urethral pressure.

Up to a 50% failure rate may be expected when genuine stress incontinence with low urethral pressure is treated with routine urethropexy. A combination of Ball and Burch procedures has been suggested as an acceptable alternative to a sling procedure for the condition. In this study, 18 women undergoing a Burch procedure and 48 undergoing a Ball-Burch procedure were available for follow-up urodynamic evaluation. The one-year objective failure rate of the Burch procedure was 38%, and that of the Ball-Burch procedure was 10%, for a statistically significant difference (P less than .05). The Ball-Burch procedure appears to be an effective means of curing women of genuine stress incontinence with low urethral pressure.