Management of cervical intraepithelial neoplasia during pregnancy with LOOP excision.

OBJECTIVE: Management of severe cervical dysplasia/possible microinvasive carcinoma during pregnancy is frequently associated with significant morbidity. The purpose of this study is to determine the efficacy of LOOP excision performed during pregnancy, and also to record the nature and frequency of complications of the procedure. METHODS: Twenty women underwent LOOP excision during pregnancy. The gestational age range was 8-34 weeks. Data concerning indications, complications, and histopathologic results were recorded. RESULTS: Fourteen of 20 (70%) had dysplastic changes in the LOOP specimen. Eight of 14 (57%) had involved margins. Nine of 19 (47%) had residual dysplasia 3 months postpartum, including 3 patients whose initial LOOP specimens were negative for dysplasia. Significant morbidity included 3 preterm births, 2 patients who required blood transfusion following LOOP, and 1 unexplained intrauterine fetal demise documented 4 weeks post-LOOP. The gestational age range of those patients who had significant morbidity was 27-34 weeks. CONCLUSIONS: LOOP excision of the cervix during pregnancy does not consistently produce diagnostic specimens and is associated with a significant rate of residual disease. Morbidity appears similar to that of cone biopsy during pregnancy and occurs primarily when the procedure is performed in the third trimester. Until refinements in technique occur, LOOP excision during pregnancy should be reserved for limited indications.

Cervical carcinoma in women less than 35 years of age.

We retrospectively studied 80 patients, less than 35 years old, who were being treated for invasive cervical carcinoma at Charity Hospital of Louisiana in New Orleans. The period covered by the study was March 1980 to November 1989. The study group represented 9.3% (80/862) of the total patients seen with the disease. Disease stage was IB in 50 patients, IIA in 4, IIB in 14, IIIA in 5, IIIB in 6, and IVA in 1 patient. Histopathologic classes included 74 squamous cell carcinomas, 3 adenosquamous carcinomas, 2 adenocarcinomas, and 1 anaplastic carcinoma. Treatment used was either radical hysterectomy, irradiation alone, or irradiation followed by hysterectomy. Five-year actuarial survival rates were as follows: stage IB, 81.6%; stage IIA, 25.0%; stage IIB, 29.8%; stage IIIA, 20.0%; and stage IIIB, 33.4%. The only patient with stage IV cancer died of disease. Our findings do not reveal a relationship between age and survival in stage IB carcinoma of the cervix, and the numbers in the other stages are too small to comment on.

Amniotic fluid embolism.

Amniotic fluid embolism is an almost universally fatal complication of pregnancy. We have presented a case and reviewed the literature concerning this rare but catastrophic problem.

Pregnancy outcome in patients with repeat visits to the labor observation area near term.

Patients whose pregnancies are near term and who repeatedly visit the labor observation area but are found not to be in labor and have no clear diagnosis for their complaints remain a source of concern for the obstetrician. In order to determine whether this is a population with special perinatal risks, such cases were reviewed over a 4-month period at Charity Hospital in New Orleans. Seventy-one patients were identified who had repeatedly visited the labor observation area near term. Compared with those in the general obstetrics population, these patients had a significantly increased risk of cesarean section for "failure to progress." Repeat visitors to the labor observation area should be viewed as having a high risk for later abnormalities of active labor. Careful management of labor abnormalities in such patients could theoretically lower their need for cesarean section.

A case report of giant cell arteritis of the uterus and adnexa.

Giant cell arteritis of the uterus and adnexa is a rare disorder, which is generally asymptomatic and occasionally associated with temporal arteritis. The true clinical significance of this dramatic microscopic finding remains obscure, but arteritis of the uterus and adnexa may be associated with later development of giant cell arteritis elsewhere in the body.

Ovarian choriocarcinoma: a difficult diagnosis of an unusual tumor and a review of the hook effect.

Ovarian choriocarcinoma is difficult to diagnose in the reproductive-age patient. A case of nongestational ovarian choriocarcinoma is discussed which presented like a molar pregnancy initially. Because of falsely low beta-hCG values (283 mIU/L) caused by the high-dose "hook effect" in the double antibody immunoassay system, however, a diagnosis of ectopic pregnancy was entertained. At laparotomy, a large necrotic ovarian choriocarcinoma was found along with large theca lutein cysts. The hook effect may mislead the clinician, and it is important to recognize this effect to avoid misdiagnosis.

Relative strength of a new suture technique for fascial closure.

In an attempt to decrease the risk of fascial dehiscence, a new suture technique for fascial closure is proposed, referred to as the "secured" stitch. The secured interrupted stitch is performed by taking a double bite of fascia at each traditional site of fascial puncture. Relative strength of the secured interrupted stitch in comparison with the simple interrupted stitch is determined in samples of fresh bovine fascia. A significantly greater force is required to disrupt fascia repaired with the secured stitch compared with a simple interrupted repair. The secured stitch may afford a greater degree of protection from fascial dehiscence.

Paget's disease of the vulva and urogenital malignancies: a case report and review of the literature.

The vulva is one of the extramammary sites which has a potential for developing Paget's Disease with which an underlying sweat gland carcinoma or breast carcinoma is frequently associated. Urogenital malignancy may be a third contender. Such a case managed by the authors herein reported and a review of the literature about such lesions support this assumption.

Verrucous carcinoma of the cervix: a report of two cases and literature review.

Verrucous carcinoma of the cervix, like verrucous carcinoma of the vulva, is commonly misinterpreted as condyloma accuminata, resulting in a protracted delay of appropriate treatment. Since the correct diagnosis depends upon histological criterion which frequently belies the malignant nature of this lesion, conveyance to the pathologist of the history, physical findings, and clinical behavior of the lesion may facilitate early recognition. Aggressive surgical procedures including exenteration should be considered as primary treatment for large lesions and recurrent lesions when local excision fails. Radiotherapy is not usually an effective treatment for verrucous carcinoma and may induce malignant transformation. To date, 27 cases of verrucous carcinoma of the cervix have been reported. Two additional cases managed in recent years by the authors and a review of the world's literature about this uncommon lesion form the basis of this report.

Epithelial ovarian neoplasms of low malignant potential.

This report presents 13 patients with epithelial ovarian neoplasms of low malignant potential. Ten patients had serous tumors, 1 had a mucinous tumor, and 2 had endometrioid tumors. Two had Stage I disease, 4 had Stage II disease, and 7 had Stage III disease. All were treated with melphalan. Second-look laparotomy was performed in 11 patients and 1 patient required subsequent exploratory laparotomy. None achieved histologic confirmation of cure. Five patients continued treatment with melphalan and underwent third-look laparotomy with findings of persistent disease. Seven patients are alive without clinically detectable evidence of disease. Four patients died of their disease and 2 patients died of melphalan-induced acute leukemia.

Granular cell tumor of the clitoris in pregnancy.

Granular cell tumors of the female genital organs represent 7-15% of all granular cell tumors reported in the literature. The majority of these genital lesions are located on the vulva. Granular cell tumor involving the clitoris is extremely rare and should be considered in the differential diagnosis of clitoral masses.

Antiemetic efficacy of high-dose corticosteroids and droperidol in cisplatin-induced emesis: a controlled trial with droperidol and metoclopramide.

The nausea and vomiting associated with cisplatin chemotherapy make care of the patient more difficult for nurses and physicians, can cause severe metabolic and pathologic sequelae, and preclude further courses of chemotherapy. Current reports suggest that the two most efficacious agents for antiemetic prophylaxis are metoclopramide and corticosteroids. These two agents in combination with droperidol have been compared in a randomized controlled prospective fashion. Patients had less nausea and vomiting on the steroidal regimen than the nonsteroidal regimen (P less than 0.05), and the duration of nausea and vomiting was significantly less on the steroidal regimen (P less than 0.05). Patients expressed a preference for the steroidal regimen over the nonsteroidal one and the steroidal regimen retained its antiemetic effectiveness through repeated courses of chemotherapy. The results of the study suggest that corticosteroids and droperidol are superior antiemetic agents for cisplatin-induced nausea and vomiting.

Tumor cell kinetics-directed chemotherapy for advanced squamous carcinoma of the cervix.

Cell cycle phase specific chemotherapeutic agents may be less effective treatment for metastatic or recurrent cervical carcinoma because most solid tumors contain very low cell growth fractions. Maximum therapeutic advantage may be accomplished through the use of a multiple drug protocol whose schedule is based on phase specificity of drug action and tumor cell kinetics. Preliminary data indicate that administration of a synchronizing agent, followed by cell kinetics analysis using flow microfluorometry techniques, allows a second agent to be scheduled at a time in the cell cycle when it would be most effective. These observations are based on the clinical response of 11 patients treated with kinetics-directed regimens (derived from direct kinetics measurements) or kinetics-based protocols (derived from empirical or historical data).

Use of 1,2:5,6-dianhydrogalactitol in studies on cell kinetics-directed chemotherapy schedules in human tumors in vivo.

Recently, it has been shown that 1,2:5,6-dianhydrogalactitol (DAG) can cause reversible alterations in cell cycle kinetics. Following treatment of CHO cells in vitro and Ehrlich ascites tumor cells in vivo, significant increases in the fraction of cells in S phase were observed to occur, and this was followed by an increase in the fractions of cells in G2 and mitosis. Treatments with S or G2-M phase-specific drugs at the peak enrichment times after DAG was given resulted in greater cell kills than when given by any other schedule. We have extended these kinetics-directed drug schedule studies to human tumors in vivo. The first phase was to determine whether DAG could be used to perturb cell kinetics in vivo as effectively in patients as it was in vitro. In 14 of 17 tumors studied, increases in the S-phase fractions were observed (ranging from 30 to 240% increases). The hr at which the S-phase peaks were observed (post-DAG treatment) was variable among the patients and among the tumors studied. However, this points out the value of obtaining actual cell kinetics data from serially biopsied tumors growing on the body surface and illustrates the importance that these data may have in helping to select an optimal time at which to give an S phase-specific drug. If such tumor cell kinetics-directed scheduling is ultimately shown to be effective, it will represent a means of individualizing therapy for a large fraction of tumor patients whose tumors are growing on or near the surface of the body. The tumors utilized in these studies were squamous carcinomas of the head and neck, skin, anus, and cervix; adenocarcinomas of the breast and rectum; and malignant melanoma. The second phase of this study will be to determine the tumor responses in patients treated with such kinetics-directed schedules.

Pelvic exenteration: analysis of 296 patients.

An analysis of 296 patients who had pelvic exenteration discloses a high risk of postoperative complications and death; however, the safety has been improved by technical modifications for urinary diversion and treatment of the denuded pelvic cavity. Recurrent cancer of the cervix or vagina was the main reason for the operation. Prognostic factors were sought to improve selection of patients who are able to withstand operation, tolerate postoperative complications, and remain free of cancer. The five-year survival rate for 296 patients with various types of cancer calculated by the Berkson-Gage method was 56.5 per cent after death from all causes were deducted, the rate was 42.1 per cent. The five-year survival rate for 196 patients with recurrent carcinoma of the cervix calculated by the Berkson-Gage method was 48.3 per cent; after deaths from all causes were deducted, the rate was 33.8 per cent.