[Metastatic placental site trophoblastic tumor. Diagnosis after pneumothorax]. / Metastasierter "Placental-site-Trophoblasttumor". Diagnose anlässlich eines Spontanpneumothorax.

Placental site trophoblastic tumor (PSTT) is a rare, mostly benign tumor, which in 10-15% of cases shows a malignant behavior. The case of a 35 year old woman with pulmonary metastasis of a PSTT is reported. This finding was incidental in an atypical lung-resection due to pneumothorax. The literature on this rare tumor entity is reviewed especially in terms of differential diagnosis, biological behavior and association with a pneumothorax.

[Premature rupture of fetal membranes at term: sequelae of conservative management. An analysis of a personal patient sample]. / Der vorzeitige Blasensprung am Termin: Folgen des abwartenden Vorgehens. Eine Analyse des eigenen Krankengutes.

Few procedures are less standardised than the procedure in case of pre-labour rupture of the membranes at term (PROM). We propose that management should be reviewed regularly on the basis of one's own data and be modified accordingly if necessary. For the duration of three months we analysed 400 pregnancies retrospectively. Patients with PROM were observed expectantly for 24 hours. If there were no spontaneous uterine contractions, labour was induced, depending on the degree of cervical dilatation. 10 percent of the cases studied had PROM. Of these a high proportion of 73 percent were primigravida, likewise 73 percent had an unripe cervix. The average time between PROM and delivery was 27 h. 50 percent of the babies were born 24 h after PROM. If delivery occurred more than 24 h after PROM, the rate of caesarean section (15 vs. 30 percent), the rate of forceps deliveries (11 vs. 20 percent), the rate of amnionitis (16 vs. 35 percent) and the number of admissions to the newborn-ICU (16 vs. 25 percent) almost doubled. The patients were examined vaginally relatively often prior to delivery (up to 18 times, with a mean of 8 times). We therefore recommend active management 6-8 h after PROM, should there be no onset of spontaneous uterine contractions. This is particularly beneficial to primigravida with an unripe cervix.

Umbilical endometriosis.

Cutaneous endometriosis is a well known but rare phenomenon. We present a case of spontaneous umbilical endometriosis. The patient revealed a polypoid, brown-blue nodule within the umbilical depression with the typical history of monthly bleeding from the umbilicus. The differential diagnoses are summarized.

Use of granisetron in patients refractory to previous treatment with antiemetics.

A multicenter, open-label, compassionate-use trial studied the antiemetic efficacy and tolerability of granisetron in patients who had failed other antiemetic therapies in previous cycles of cytostatic chemotherapy. The antiemetics that had been used previously included metoclopramide, dexamethasone and ondansetron. A total of 517 patients, 456 of whom had failed other antiemetics, were treated in up to 15 successive cycles of chemotherapy. The numbers of patients treated in the first six of these cycles were large enough to allow the drawing of meaningful conclusions from the results. During that period, a complete response was achieved in 53-60% of patients. In addition, antiemetic efficacy was sustained throughout these six repeated treatment cycles. Granisetron was less effective against high-dose cisplatin chemotherapy than against other cytostatic regimens. The treatment was well tolerated--the main adverse events reported were headache and constipation; no serious adverse events were considered to be attributable to the drug. It is concluded that granisetron treatment was effective and well tolerated in patients who had previously failed other antiemetic therapies, including treatment with 5-hydroxytryptamine3 antagonists.

Epidermal-growth-factor receptor correlates negatively with cell density in cervical squamous epithelium and is down-regulated in cancers of the human uterus.

The role of the epidermal-growth-factor receptor (EGFR) in cervical cancer is controversial, due to technical difficulties in localizing or in quantifying EGFR by homogenate assays or immunohistochemistry. Our autoradiographic approach, in combination with morphometry, allowed cell-type-specific quantification of EGFR, leading to the following observations: (i) In normal cervical epithelium, EGFR levels per cell were high in non-dividing squamous cells of the upper layers of normal epithelium, where a mitogenic function of these EGFRs can be excluded. (ii) In contrast to earlier findings in tissue homogenates, but consistent with our observation in normal cervical epithelium that cells of the proliferating strata (basal and parabasal cells) express intermediate and comparatively reduced levels of EGFR per cell, cervical cancers displayed a significant reduction both of specific EGF binding and of EGFR levels per cell as compared with normal epithelium. (iii) A significant negative correlation of cell density and EGFR number per cell was obtained. In normal cervical epithelium, cervical intra-epithelial neoplasia and invasive cervical cancer (p = 0.002). This negative correlation was most evident in normal epithelium, where large changes of cell density occur within one slide (p < 0.001). (iv) Specific EGF-binding was also significantly reduced in endometrial cancers when compared with normal endometrium. It is proposed that in uterine tissues low or intermediate levels of EGFR do not exclude their function as mediators of cell proliferation.

mRNA expression of ligands of the epidermal-growth-factor-receptor in the uterus.

Six different ligands of the epidermal-growth-factor receptor (EGFR) have been identified in the past. In some cervical squamous-cell carcinomas, an increased amount of proteins binding to the EGFR has been reported. In order to identify the mRNA of EGFR ligands (EGFRL), which might be overexpressed in cervical and endometrial cancers, we performed semi-quantitative reverse-transcription/polymerase chain reactions (RT-PCR) for all 6 EGFRL in RNA extracts of normal and malignant tissue samples of the human uterus. PCR products from RNA extracts of 83 patients were quantitated relative to the housekeeping gene and internal standard pyruvate dehydrogenase by analyzing the PCR kinetics of product synthesis. In extracts of normal cervix, the level of mRNA expression of the EGFRL was significantly higher than in endometrium. No significant difference was detected between normal cervix and cervical carcinomas. However, both in cervical and in endometrial cancers, mRNA expression was non-parametrically distributed and in some cervical cancers overexpression of transforming growth factor alpha (TGF-alpha), amphiregulin or EGF was observed. In endometrial cancers, mRNA levels of all EGFRL were higher than in normal endometrium. This increase was significant (p < 0.005) for TGF-alpha and amphiregulin. Thus, TGF-alpha mRNA is overexpressed in approximately 10% of cervical cancers and in the majority of endometrial cancers. Since TGF-alpha anti-sense therapy might represent a future strategy in such cancers, we also determined the absolute level of TGF-alpha mRNA expression by quantitative PCR using a cloned standard.

[Complications after 106 laparoscopic hysterectomies]. / Komplikationen nach 106 laparoskopischen Hysterektomien.

At our hospital in Hamburg 106 patients underwent laparoscopic hysterectomies. 92 patients had no complications, but 6 had major and 10 minor ones. As major complications occurred: one vesico-vaginal fistula, one uretero-vaginal fistula, one ureter injury, one lesion of the small intestine and two bladder injuries. As minor complications could be found: six urinary tract infections, one anemia (Hb 7,1 g/dl) and one febrile morbidity. The overall complication rate is 13.2%.

Gliomatosis peritonei combined with mature ovarian teratoma: immunohistochemical observations.

Gliomatosis peritonei (GP) is the metastatic implantation of glial cells within the peritoneal cavity of patients with ovarian teratomas. The case of a young woman is presented, who initially developed a mature teratoma in the left ovary that was surgically removed. Nine years later a mature teratoma in the right ovary was excised, upon which GP was found in the greater omentum. To identify the cellular composition of the ovarian teratoma and of the omental implants, immunostainings were performed using antibodies against glial and neuronal antigens as well as against determinants of hematopoietic cells. In the teratoma the neuroectodermal part was strongly HNK-1-positive and contained GFAP- and vimentin-positive astrocytes and some NSE-positive neuron-like cells. In addition, neuroectodermal tissue was infiltrated by numerous CD68-positive macrophages/histiocytes and CD20-positive B lymphocytes. The omental nodules consisted of astrocytes, which expressed GFAP, vimentin and desmin. The implants also contained macrophages/histiocytes, which exhibited morphologic features reminiscent of microglial cells. In GP, macrophages might release glia-promoting trophic factors, which could allow the neural component of ovarian teratoma to implant in the peritoneal cavity and survive there for many years. Macrophage-derived factors might induce astroglial differentiation, which could explain why the peritoneal implants are mostly mature even when they originate from immature teratomas.

[Hormonal replacement therapy and oral contraception. Risk of induction or reactivation of gynecologic malignancies]. / Hormonelle Substitution und orale Kontrazeption. Risiko der Induktion oder Reaktivierung gynäkologischer Malignome.

The administration of oral contraceptives does not enhance the incidence of gynecologic malignancies. Only few subgroups of patients seem to have a slightly elevated relative risk of breast cancer. On the other hand, the incidence of endometrial and ovarian cancer is markedly reduced. This is also true for correct hormonal replacement therapy. In addition, no elevation of breast cancer risk has been evidenced for low-estrogen administration. In most cases, hormonal replacement therapy may also be performed safely following successful treatment of gynecologic cancers.

[Postoperative pain in patients after conventional abdominal and endoscopic surgery hysterectomy--a comparative study]. / Postoperative Schmerzen bei Patientinnen nach konventioneller abdominaler und endoskopisch operativer Hysterektomie--eine vergleichende Untersuchung.

The purpose of the present study is to determine differences in the postoperative character of pain between two study groups undergoing different techniques of hysterectomy. Therefore we examined 42 women. 21 women underwent combined laparoscopic and vaginal hysterectomy and 21 abdominal hysterectomies have been performed. All patients received on request Piritramid i.m. exclusively as an analgesic. The following factors have been included: 1. location of pain, 2. duration of pain, 3. maximum of pain, 4. analgesic requirements, 5. return to normal physical activities. With regard to our findings it seems to be certain that endoscopic operative hysterectomy compared to abdominal hysterectomy shows diminished duration of pain and reduction in the total amount of analgesic usage, as well as a shortened time to return to normal physical activities.

Experimental animal model for readhesion formation study.

The problem of postoperative adhesions remains unsolved. The formation of readhesions after tubal reconstructive surgery reduces the success rate. We have developed a modified uterine horn model in the rat to study the influence of peritoneal transplants on readhesion formation. A total of 58 rats were operated. In 25 animals (group III) the uterine horn was scratched on both sides and then sutured together. During relaparotomy 14 days later the tight connection between both sides was cut. The resulting defect was covered by a peritoneal transplant on one side (group IIIb) and was left open on the control side (group IIIa). After 14 days the presence or absence of adhesions was explored. There was a significant difference (p < .001) between the covered (28%) and uncovered (84%) peritoneal defects with respect to incidence of adhesions. To compare the different characteristics of visceral and parietal peritoneum, a pelvic sidewall defect was induced in 33 animals. There was no significant difference between covering the defect by a peritoneal transplant (group II; 42.9%) and the control side (group I; 33.3%). These data suggest that defects on visceral peritoneum should be closed to prevent adhesion formation. The incidence of adhesions after injury of parietal peritoneum seems to be much lower and of less clinical significance.

[EGF receptor and EGF-like activity as prognostic factors in cervix cancer]. / Der EGF-Rezeptor und die EGF-ähnliche Aktivität als Prognosefaktoren beim Zervixkarzinom.

The binding of the Epidermal Growth Factor (EGF) and the amount of EGF-like activity (EGF-A) was analysed in 75 cervical carcinomas and possible clinical implications were tested. EGF-A was significantly increased in patients with metastases to the pelvic and/or para-aortic lymph nodes. The EGF-receptor (EGF-R) capacity was inversely related to the histological grade (p < 0.05) and was reduced in highly differentiated tumours. In stage I and II disease, the clinical outcome was significantly reduced, if the receptor capacity or the level of EGF-A was increased (> 100 fmol/mg protein and > 0.5 ng/mg protein, respectively). The measurement of EGF-R capacity and EGF-A provides new and additional information for the prediction of the prognosis in cervical cancer.

[Age-related differences and changes in clinical aspects and follow-up of cervix cancer since 1973]. / Altersabhängige Unterschiede und Veränderungen in Klinik und Verlauf des Zervixkarzinoms seit 1973.

In an attempt to clarify, whether the malignant potential of cervical cancer is age-dependent and whether this has changed in the last decade, we analysed the data from 1496 patients suffering from cervical cancer. The patients were treated between 1973 and 1988 at the second Universitäts-Frauenklinik, Lindwurmstrasse and at the Frauenklinik Grosshadern, both of the Ludwig-Maximilians-Universität München. After 1973, the total number of patients with cervical cancer decreased, whilst at the same time, the percentage of young patients increased. In the sub-group of surgically treated patients (n = 555), the percentage of patients with lymph node metastases increased after 1973. The increase in lymph node involvement was most pronounced in young patients with small tumours (stage Ib disease, 35 years of age). In this group, the percentage of lymph node involvement rose from 6.3% in 1973 to 38.6% in 1988. Lower stage disease was significantly more frequent in the young patients. Accordingly, the overall mean survival time was longer in the young patients. In the sub-group of surgically treated patients, however, when comparing equal stages, the survival time was shorter in the young patients. In small tumours (confined to the uterine cervix), pelvic lymph node involvement was more frequently seen in the younger patients. Secondary metastases developed more rapidly and significantly more often in the young patients. Our data supply evidence to indicate an enhanced malignancy of cervical cancer in young patients.

Clinical implications of the epidermal growth factor receptor in the squamous cell carcinoma of the uterine cervix.

The clinical implications of the epidermal growth factor (EGF) and its receptor (EGF-R) were studied in 52 squamous cell carcinomas of the uterine cervix. In comparison to 40 biopsies of the normal cervix EGF-R capacity was significantly increased in the carcinomas, while the affinity was unchanged. The amount of EGF-like substances extracted from the tumors was increased in patients with lymph node metastases, in whom 5-year survival is reduced. Irrespective of tumor stage patients with a very high level of EGF-R (greater than 100 fmole/mg protein) were more likely to have recurrences later or to die from disease: recurrence or death occurred in 5 of 7 patients with high capacity and in 2 of 45 patients with low capacity. Our data suggest that the level of EGF-R is indicative of the biological aggressiveness of cervical carcinomas.

Modern synthetic suture materials and abdominal wound closure techniques in gynaecological surgery.

The introduction of modern synthetic suture materials and an individualized approach to wound closure techniques in gynaecological surgery has created new options. Although many issues remain open to question, we have no doubt that catgut and chromic catgut can be declared obsolete in gynaecological surgery. The choice of synthetic suture materials has to be made on personal preferences and clinical experience. If the use of non-absorbable sutures is desired, with few exceptions monofilament suture material is clearly the first choice. Abdominal opening and closure techniques and the selection of appropriate suture materials have to be considered as important factors in minimizing wound healing complications. The decision-making process is based on the knowledge of anatomy, wound healing and possible risk factors. From theoretical considerations, mass closure of all layers apart from skin is considered to be the superior concept. The incidence of incisional hernias and sinus formation will depend on proper technique and possibly the choice of suture material. Some suggestions to individualize opening and closure of the abdomen are made although prospective randomized trials in gynaecology have not yet been performed.

[Pathology of proximal tubal occlusion--morphologic evaluation. Results following microsurgical anastomosis]. / Die Pathologie des proximalen Tubenverschlusses--Morphologische Auswertungen. Ergebnisse nach mikrochirurgischer Anastomose.

Even today, the etiology of proximal tubal occlusion is still a controversial subject. The introduction of microsurgery in gynecology has provided a method of eliminating the main symptom of proximal tubal occlusion, i.e., sterility. Pregnancy rates of 25-30% can be achieved in overall patient collectives. Accurate histologic analyses of the specimens are essential for clinicopathological classification in three prognosis groups. For stage I patients, pregnancy rates of up to 50% (patient-related) can be achieved. Postoperative counseling can thus be differentiated on the basis of the histological results. For stage III patients the pregnancy rate is unlikely to be acceptable, even after waiting for a prolonged period of time. It has not been established whether reconstructive tubal surgery or alternative therapeutic procedures (I.V.F. and E.T.) have better chances of success in stage II. Accurate histologic analysis of the surgical specimens is an essential prerequisite for individualized sterility counseling and therapy.