Combination of cervical interleukin-6 and -8, phosphorylated insulin-like growth factor-binding protein-1 and transvaginal cervical ultrasonography in assessment of the risk of preterm birth.

OBJECTIVE: To determine the value of combinations of cervical interleukin-6 (IL-6), cervical interleukin-8 (IL-8), the phosphorylated isoform of insulin-like growth-factor binding protein-1 (IGFBP-1), and cervical ultrasonography in the prediction of preterm birth. DESIGN: Prospective follow up. SETTING: Oulu University Hospital maternity clinic from February 1997 to July 1998. POPULATION: Women with singleton pregnancies (n = 77), referred from outpatient clinics at 22-32 weeks of gestation with symptoms (uterine contractions) or signs (cervical change) of threatened preterm birth. Symptomless women (n = 78) matched for gestational age, parity and maternal age at recruitment were studied as a reference group. METHODS: A urine sample for bacterial culture was collected, and cervical swab samples for assays of interleukin-6 and -8 and phoshorylated IGFBP-1 were taken before digital cervical examination. A Pap smear for analysis of bacterial vaginosis and samples for analysis of chlamydia and streptococci were also obtained. Cervical measurements were made by transvaginal ultrasonography. The same sampling and cervical measurement were repeated twice at two-week intervals. The cutoff values of the markers were determined by receiver-operating characteristic curve analysis. MAIN OUTCOME MEASURE: Preterm birth (<37 weeks). RESULTS: The preterm birth (<37 weeks) rate for women in the study group was 16% (12/77). The cervical interleukin-6 cutoff value (61 ng/L) at first visit had a sensitivity of 73% and a specificity of 61% in predicting preterm birth, with a positive likelihood ratio (LR+ ) of 1.9 (95% CI 1.2-3.0). An ultrasonographically measured cervical index value of > 0.36 at recruitment predicted preterm birth in 25% (5/20) of the study group compared with 9% (5/54); LR+ 2.2 (95% CI 1.03-4.7). Cervical phosphorylated IGFBP-1 > 6.4 microg/L [LR+ 1.8 (95% CI 0.7-2.9)], interleukin-8 > 3739 ng/L [LR+ 1.4 (95% CI 0.9-2.4)], and ultrasonograpic cervical length < 29.3 mm [LR+ 2.7 (95% CI 0.8-9.7)] increased the risk of preterm birth. According to the logistic regression model, a combination of IL-6, and IL-8 and cervical index increased the specificity to 97%, but the sensitivity fell to 30% in detecting preterm birth. There was a significantly increased incidence of puerperal infections if phosphorylated IGFBP-1 concentrations were elevated (> 21.0 microg/L), 36% (4/11) compared with 4.6% (3/65), LR+ 6.7 (95% CI 2.7-17), the sensitivity being 67% (4/6) and the specificity 90% (63/70). Elevated phosphorylated IGFBP-1 concentrations (> 21.6 microg/L) were also associated with an increased risk of neonatal infections; LR+ 8.0 (95% CI 3.5-18). CONCLUSIONS: An increase in cervical IL-6 concentration and the ultrasonographically measured cervical index appear to be associated with preterm birth. A combination of these markers with measurement of cervical IL-8 appears to be the best predictor of preterm birth. Neither the sensitivity nor specificity of the tests used in this study are good enough to predict preterm birth for clinical decision making. Cervical phosphorylated IGFBP-1 seems to be a marker of puerperal and neonatal infectious morbidity in cases of threatened preterm delivery, suggesting early tissue degradation at the choriodecidual interface.

A randomised controlled trial of vaginal clindamycin for early pregnancy bacterial vaginosis.

OBJECTIVE: To determine whether treatment of bacterial vaginosis (BV) with vaginal clindamycin affects pregnancy outcome. MATERIALS AND METHODS: Mothers with singleton pregnancies and without previous preterm delivery in 17 health centres in Oulu from March 1996 Until March 1998, in whom BV was diagnosed by Gram stain of a vaginal swab at the first antenatal visit (at the 12th gestational week) were randomised at Oulu University Hospital to have a one-week course of vaginal clindamycin, or placebo. A follow up sample of Gram stain was taken two weeks after randomisation and at the 30th gestational weeks. Pregnancy outcome data was obtained from hospital records. Primary outcome was preterm birth, and puerperal infectious morbidity the other outcome measure. RESULTS: During the study period 1956 women were screened, of whom 143 (7.3%) were BV- positive. One hundred and one were randomised. The total preterm birth rate of BV+ women randomised was 9.9% (10/101). Preterm birth occurred in 20.7% (6/29) vs 0% (0/26) according to whether BV persisted or not (P < 0.01). The preterm birth rate was 13.7% (7/51) in the clindamycin group vs 6.0% (3/50) in the placebo group (OR 2.5, 95% CI 0.6-10). BV was cured just after treatment in 17 out of 51 (33%) of the clindamycin- treated patients vs 17 out of 50 (34%) of the placebo- treated patients (OR 1.0, 95% CI 0.4-2.2). There was a difference in puerperal infectious morbidity in patients where BV persisted (31%, 9/29) compared with those in which BV did not persist (7.7%, 1/26) (OR 5.4, 95% CI 1.04-28). Infections were seen in 4/51 (8%) of the clindamycin treated vs 10/50 (20%) of the placebo treated cases, (OR 0.3, 95% CI 0.1-1.2). CONCLUSION: The prevalence of BV was lower than expected in this low risk population, but nevertheless it increased the risk of preterm birth and puerperal infectious morbidity, the risk being highest in cases where BV persisted during pregnancy. Vaginal clindamycin treatment for BV in the first trimester of pregnancy did not appear to reduce the risk of preterm birth or puerperal infections.

The prognostic value of peritoneal cytology in ovarian cancer.

We studied the significance of peritoneal cytology as a prognostic factor in primary epithelial ovarian cancer. Intraperitoneal specimens for cytological examination were taken from 73 patients at primary operation for ovarian cancer. The prognostic value of cytological findings was analyzed by the Kaplan-Meier method. It was also correlated to clinical stage, tumor histology, histopathological grade, residual tumor, presence of ascites and age by using the chi2-test. The value of cytology in relation to other factors was assessed by Cox-multivariate analysis. In univariate analysis peritoneal cytological findings correlated significantly to survival. In Cox-multivariate analysis peritoneal cytology, histopathological grade and the age of the patient were found to be significant independent prognostic factors in epithelial ovarian cancer. According to this data peritoneal cytology can be considered as an important prognostic factor in ovarian cancer. Therefore it should be evaluated routinely in association with surgery of ovarian tumors.

Tenascin in human papillomavirus associated lesions of the uterine cervix.

The immunohistochemical expression of tenascin was studied in 80 morphologically diagnosed condylomas and cervical intraepithelial neoplasia (CIN) lesions. The results were compared with the human papillomavirus (HPV) DNA subtype, which was determined by HPV dot blot and in situ hybridisation. Tenascin mRNA synthesis was also determined in 10 selected cases by in situ hybridisation. No statistically significant association was found between tenascin expression and the degree of dysplasia or the HPV subtype. There was, however, a strong correlation between the extent of tenascin immunoreactivity and the degree of inflammation. Synthesis of tenascin mRNA was detected in basal keratinocytes and in fibroblasts by in situ hybridisation. The lack of association between the grade of CIN and tenascin expression precludes its use as a marker of premalignancy in CIN.

Maturation of vaginal and endometrial epithelium in postmenopausal breast cancer patients receiving long-term tamoxifen.

To assess the estrogenic effects of tamoxifen on vaginal and endometrial epithelium and to investigate whether these changes are associated with any pathological findings in the endometrium, 53 postmenopausal breast cancer patients receiving long-term tamoxifen and 52 control breast cancer patients without any hormonal treatment were examined. Pathological findings in the endometrium were evaluated by hysteroscopy and curettage. The main outcome measures were the maturation index in Papanicolaou (Pap) smears, estrogen-like epithelial changes in the endometrium, serum concentrations of gonadotropins, sex hormone-binding globulin (SHBG), estradiol (E2), and testosterone (T). Informative Pap smears showed estrogenic effects in 89% (41/46) of the tamoxifen group and in 49% (22/45) of the control group, and in endometrial aspiration samples in 71% (32/45) and in 41% (19/46), respectively. These changes were associated with increased concentrations of serum E2 in the control group but not in the tamoxifen group. All five patients (11%) with endometrial polyps in the control group showed estrogenic endometrial changes, whereas among 14 women with polyps in the tamoxifen group, 9 showed estrogenic changes and 5 endometrial atrophy. Endometrial adenocarcinoma was found in 3 patients in the tamoxifen group and in 2 in the control group. Pap smears showed atrophy in 2 patients in the former and in one in the latter group. These findings confirmed estrogen-like effects of tamoxifen on the vaginal and endometrial epithelium in postmenopausal breast cancer patients, but these were not closely associated with benign or malignant endometrial lesions.

Expression of p53 and proliferating cell nuclear antigen in lichen sclerosus et atrophicus with different histological features.

In this study, immunohistochemistry was used to investigate p53 and proliferating cell nuclear antigen (PCNA) expression in 40 cases of lichen sclerosus et atrophicus (LSA). Nuclear immunoreactivity for both p53 and PCNA was found in the basal and parabasal keratinocytes in the majority (91%) of the lesions. Typically, there was a widely varying positivity for PCNA, suggesting a wide range of proliferative capacity in individual LSA lesions. Lesions with p53 positivity in 5% or more of the basal cells also presented a strong (> 14% of basal cells positive) PCNA positivity (p = 0.030) and exhibited a higher mitotic rate (p = 0.002), suggesting a causal relationship between enhanced p53 expression and elevated cell proliferation. Lesions with a low number of PCNA-positive cells (< 15% of basal and parabasal cells positive) exhibited a wider subepithelial edematous zone and a thinner epithelium than in the lesions with a higher number of PCNA-positive cells. The results show that later stages of LSA, typified by subepithelial edema and epithelial atrophy, are associated with decreased proliferative activity of the basal and parabasal cells.

Acitretin in the treatment of severe lichen sclerosus et atrophicus of the vulva: a double-blind, placebo-controlled study.

BACKGROUND: Promising results have been reported from treatment with oral retinoids in patients with severe lichen sclerosus et atrophicus (LSA) of the vulva. OBJECTIVE: The aim of our study was to determine the efficacy of acitretin (20 to 30 mg/day) for 16 weeks in LSA. METHODS: Seventy-eight patients were enrolled into a multicenter, randomized, placebo-controlled, double-blind trial. The primary measure of efficacy was the "responder" rate based on the assessment of characteristic clinical features of LSA of the vulva (pruritus, burning, atrophy, hyperkeratosis, and secondary features such as erosions, ulcers, edema, or lichenification) and on the extent of the lesions. RESULTS: From the 46 patients eligible for efficacy analysis, a significantly higher number of responders was observed in the acitretin-treatment group (14 of 22 patients) as compared with the placebo-treatment group (6 of 24 patients). Typical retinoid adverse reactions were observed in all patients receiving active drug. CONCLUSION: Acitretin is effective in treating women with severe LSA of the vulva.

Detection of human papillomavirus infection by non-isotopic in situ hybridisation in condylomatous and CIN lesions.

AIMS: To study the value of non-isotopic in situ hybridisation (NISH) in detecting human papillomavirus (HPV) infection in female genital lesions positive for the virus by conventional histology but negative by filter DNA hybridisation. METHODS: Forty three cases, which showed the histological hallmarks of the HPV infection but produced negative results in filter dot blot hybridisation tests (Vira Pap and Vira Type kits), were identified in the course of an investigation of 304 vaginal, vulvar, and cervical samples from 267 patients. These cases were studied by NISH for the presence of HPV infection. RESULTS: In 28 (65%) of the cases NISH gave a positive hybridisation signal. In 26 cases (96%) the signal was diffuse, and in two (4%) punctate or diffuse, representing episomal and episomal or integrated HPV DNA, respectively. In most cases only a few HPV positive cells were discernible. CONCLUSION: NISH is a more sensitive technique than dot blot hybridisation, detecting HPV infection in most cases which show histological HPV atypia but which remain negative in filter DNA hybridisation. Thus NISH is useful as an additional technique to verify the presence of HPV in lesions which remain negative in filter hybridisation tests.

Detection and typing of human papillomavirus infection affecting the cervix, vagina and vulva. Comparison of DNA hybridization with cytological, colposcopic and histological examinations.

The sensitivity of human papillomavirus (HPV) detection was compared by colposcopy, histology and DNA hybridization among 304 women with abnormal Papanicolaou (Pap) smear. Colposcopically directed biopsies revealed HPV infection in 71% of cases, DNA hybridization in 35%, and both together in 78%. DNA hybridization detected HPV in 24% of the 84 benign cases with no histological signs of HPV, in 32% of the 133 condylomas verified by biopsies and in 51% of the 85 cases with intraepithelial neoplasia, 95% of which presented histological signs of HPV. The pattern of occurrence of different HPV-types resembled findings in earlier reports. HPV infection is common with abnormal Pap smears and it can be identified relatively reliably by means of cytology, colposcopy and histology. DNA hybridization serves as a complementary technique which may reveal the oncological potential of the virus.

Endobrush sampling for endometrial cancer.

The two intra-uterine cytological sampling methods Endobrush and Pistolet were compared for clinical applicability in 66 premenopausal and 47 postmenopausal women. The taking of the specimens succeeded in 94% of the cases with the Endobrush method and in 99% with the Pistolet method. The two intra-uterine sampling methods were both almost painless. The Endobrush and the Pistolet specimens were filtered and stained by the Papanicolaou method. The Endobrush specimens were also used to make smears, which were also stained by the Pap method. According to the separate evaluations of two cytologists the Endobrush smear yielded specimens with a large or moderate number of cells in 59.0 to 71.4%, the Endobrush filter method in 73.6 to 76.5% and the Pistolet filter method in 71.4 to 76.8%. Specimens with good or moderate quality were found in 83.3%, 86.8 to 89.6% and 93.7 to 99.1%, respectively. Unsatisfactory specimens accounted for only 2.8-0.9% of the cases. All four endometrial carcinomas were placed in Pap classes 3 to 5 on the basis of the Endobrush and Pistolet filter specimens. The diagnostic quality of the smears was inferior to that of the filter specimens. The results suggest that the Endobrush filter method yields cytological endometrial samples which are similar in cell number, quality and diagnostic value to those obtained by the Pistolet method. Endobrush method is also simple, quick and painless, and therefore well acceptable to patients and suitable for clinical use.

Anaerobic vaginosis: treatment with tinidazole vaginal tablets.

A prospective randomized trial comprising 90 patients was undertaken to evaluate three different regimens of tinidazole in the treatment of anaerobic vaginosis. Each group consisted of 30 women. The three regimens were: (A) oral tinidazole (150 mg X 2) for 7 days, (B) same oral treatment as above but also the partner received 500 mg X 2 for 4 days, and (C) intravaginal tinidazole (500 mg) at bedtime for 2 weeks. After clinical diagnosis and treatment the patients were reassessed at 1 and 3 months. The overall cure rate was significantly (p less than 0.05) higher in group C than in the other groups. After 3 months, 70% of the cases in group C were asymptomatic, while in the other groups the rate was 42 and 43%, respectively. The intrauterine contraceptive device (IUCD) played an important role in the etiology of relapses and also in the decreased cure rates particularly seen in groups A and B. Among the women in group C using an IUCD, 80% were cured, while in groups A and B only 30 and 29% were cured. All regimens were well tolerated. The treatment of anaerobic vaginosis with vaginal tinidazole was effective and particularly useful if an IUCD was in concurrent use.

Tamoxifen and natural progesterone as supplements to low-dose postmenopausal estrogen therapy.

Postmenopausal women received 1 mg estrone sulfate a day for 3 weeks in 12 sequences separated by a 7-day interval without medication and every second time by a 10-day treatment with natural progesterone, 100 mg 2 times daily (n = 16), or tamoxifen, 10 mg 2 times daily (n = 17). Both treatments alleviated climacteric symptoms, maturated the vaginal epithelium, and decreased follicle-stimulating hormone, luteinizing hormone, and prolactin concentrations while lipid metabolism remained unaltered. In the estrogen-progesterone group 4 women (25%) were persistently amenorrheic, 12 (75%) experienced 1-5 bleedings per year, and 4 women had proliferative endometrium after treatments. In the estrogen-tamoxifen group 11 women (65%) were amenorrheic, 6 (35%) had 1-4 bleedings per year, and 5 had proliferative endometrium. With the present treatment schedules, tamoxifen was more effective than natural progesterone in inhibiting estrogen stimulation of postmenopausal endometrium.

Screening of asymptomatic postmenopausal women for gynecological malignancies, with special reference to endometrial sampling methods.

To investigate the applicability of cytological and histological endometrial sampling methods and to study the incidence of silent premalignant or malignant gynecological diseases during the postmenopausal years, 415 asymptomatic women were examined both clinically and with cytological smears and 360 of them also examined with jet wash or pistolet aspiration and Vabra curettage. Examination with jet wash, pistolet aspiration and Vabra curettage was possible in 57.2%, 83.1% and 76.1% of the cases, respectively. The cytological specimens (jet wash, pistolet) and the Vabra curettage specimens were inadequate in 3.7% and 44.5% of cases, respectively. Our study revealed two malignant (one mammary and one gastric cancer with ovarian metastases), seven premalignant (four endometrial and three cervical) and 55 benign gynecological or mammary lesions, amounting to 15.4% of the 415 women. These results, with only four severe endometrial lesions, indicate the restriction of endometrial screening examinations to only well-defined high risk women. Of the methods used, the pistolet aspiration is the most recommendable due to its applicability, patient acceptance, diagnostic reliability and the low incidence of unsatisfactory samples.

Investigation of gynecological cancer with nuclear magnetic relaxation methods.

Nuclear magnetic relaxation times T1 and T2 of cell water protons in benign and malignant uterine cervical tissue (37 samples taken from 22 patients) were measured using a resonance frequency of 19.8 MHz. The means of relaxation times recorded for malignant tissue were (mean +/- S.E.) T1 = 0.89 +/- 0.05 s, T2 = 0.072 +/- 0.009 s, and obtained from corresponding benign tissues (mean +/- S.E.) T1 = 0.72 +/- 0.01 s T2 = 0.056 +/- 0.003 s. The differences are statistically significant (T1:p less than 0.001, and T2:p less than 0.05). The effect of dysplasia and inflammatory changes in mucosa to the relaxation times were examined and the probable sources of error in the present method are discussed.