Misconceptions about routine colposcopy.

Colposcopy is practised in two ways: (1) to assess women with abnormal screening findings and/or clinically suspicious cervix (called referral colposcopy), and (2) as part of a routine gynaecological examination (referred to as routine colposcopy). There are several misconceptions about routine colposcopy probably reflecting the lack of experience in using routine colposcopy. Misconceptions include: routine colposcopy is screening colposcopy, it is time-consuming, expensive, a waste of time, and the training and maintaining of colposcopic expertise is probably not sufficient in this setting. Routine colposcopy, however, is not a screening tool, it is not screening colposcopy, but capable of identifying cervical precursors and cancer, and thereby reducing the false rates of cervical cancer screening (mainly cytology). Unlike referral colposcopy, routine colposcopy is an inexpensive and rapid procedure conducted as a part of a pelvic examination and has no, or minimal, discomfort that certainly does not exceed that of smear taking, neither is it associated with any psychological burden. Routine colposcopy allows gynaecologists to be convincingly sure in their findings; ensure women having normal epithelium; evaluate abnormalities in details (without biopsy) and counsel patients immediately to alleviate the psychological effects and prepare them for a possible abnormal smear; as well as help make a diagnosis of obscure lesions.

HE4--a novel promising serum marker in the diagnosis of ovarian carcinoma.

Biomarkers have a wide range of applications in the management of several cancers. To date serum markers have been the most extensively used biomarkers in everyday practice but few markers are elevated in preclinical or premalignant disease, limiting their importance for estimating risk or for screening. Human epididymis protein-4 (HE4) is a novel serum marker which is more sensitive in the prediction of risk of ovarian malignancy than CA125 alone in patients with a pelvic mass. HE4 in combination with CA125 appears to be an effective tool for the early detection of recurrence or monitoring the response to therapy. Risk of Ovarian Malignancy Algorithm, utilizing the dual marker combination of HE4 and CA125, can be used to stratify both postmenopausal and premenopausal women into high- and low-risk groups, allowing for an effective triage of women to appropriate institutions for their care. A review of HE4 and its feasibility as a novel diagnostic tool in the management of epithelial ovarian cancer is presented.

Tissue-based classification of HPV infections of the uterine cervix and vagina (mucosal HPV infections).

Terminology of HPV infections of the uterine cervix and vagina is somewhat confusing, with various terms having different meanings to different authors. This prompted us to revise the current terminology and propose a "tissue-based" classification of HPV infections of the cervix and vagina (mucosal HPV infections), which is based on histological appearance of the lesions and should be clear-cut in everyday practice of managing these patients. We hope the proposed nomenclature may overcome some of the confusion and controversy that exist in the current terminologies describing these lesions.

Perrault's syndrome in two sisters.

We report on two sisters with Perrault's syndrome, i.e., autosomal recessive ovarian dysgenesis associated with sensorineural deafness. They were deaf-mute and of normal height with a few minor somatic anomalies. Both had streak gonads and an apparently normal female 46,XX chromosome constitution. The parents were apparently not consanguineous. The mother had normal hearing. Other relatives were not available for study. Epilepsy, which occurred in three relatives including one of the index patients, may have been inherited coincidentally from the mother's family.

Comparative cytogenetical and morphological studies in ovarian dysgenesis.

In 14 cases of the Turner syndrome and pure gonadal dysgenesis streak gonads were studied histologically. In cases where the 46,XX line was unimpaired the blood vessels of the gonad showed severe degeneration in at least 30 to 50%. These streak gonads usually contained some of the characteristic ovarian elements as well as the vascular lesions. In gonosomal monosomy, on the other hand, a similar intensive vascular degeneration could not be found and the gonad consisted of indeterminate connective tissue. These observations are strong indications of a close correlation between karyotype and the histology of the streak gonad, which may supply further information on the manner and timing of the development of the streak gonad.

The streak gonad syndrome.

The streak gonad syndrome is described in detail with a reveiw of the literature and a report on the diagnosis of 38 additional patients. Certain signs and symptoms of the syndrome are always present, ie, female phenotype, primary amenorrhea, infantile breast status, sparse public and axillary hair, infantile external genitalia and vagina, atrophic vaginal smear, immature uterus, high serum follicle-stimulating hormone (FSH) level, low urinary estrogen, retarded ossification, osteoporosis, and the streak gonad. Therefore, they are considered to be cardinal features. Certain somatic anomalies known as associated stigmata occur with varying frequency in accordance with the karyotype. Thus, patients with the streak gonad syndrome can be classified into groups according to their chromosomal complements. It is believed that the term streak gonad syndrome instead of Turner's syndrome, gonadal dysgenesis, or other terms is a much more accurate description of the syndrome, at least from the clinician's point of view.

Vascular injuries in the surgical management of gynaecological malignancies.

From 1989 to 1991 we performed 184 radical gynaecological interventions. In the vast majority of the cases lymph node dissection was part of the procedure. Thirteen out of the 184 patients suffered vascular injury, accounting 7% complication rate. The sites of the injured vessels included the external iliac artery in four patients, the vena cava in three, the external iliac vein in five and the femoral vein in one patient. All of them were primarily sutured; no prosthesis or venous patch was needed. In four cases postoperative complications occurred in relation to vascular surgery: two deep thrombosis of the femoral vein and two occlusions of the external iliac artery. The latter two patients had permanent sequelae, i.e. difficulties in walking. Our study suggests that vascular injuries represent an utmost important intraoperative risk in the course of lymph node dissection in gynaecological malignancies. Thus, gynaecological surgeons performing radical operations must be prepared to deal with the problem.

Perioperative complications of 116 radical hysterectomies and pelvic node dissections.

Perioperative morbidity and mortality were studied in 116 patients who underwent radical hysterectomy and lymph node dissection. Type II radical hysterectomy was performed in two, type III in 97, type IV in 12 and type V in five patients, and the perioperative morbidity was assessed accordingly. Because of the short follow-up time the late sequelae could not be evaluated. There was no operative death. Haemorrhage was the most common complication and it was more frequent and serious in type IV and V classes. Prolonged bladder atony was also frequent, particularly in type IV radical hysterectomy. The infection rate was comparable. One patient developed ureteric fistula, and one woman had ureteric stricture. Lymphocyst formation, nerve damage, lymphoedema and thromboembolic disease were rarely encountered and there was no bowel obstruction. Injury to the great vessels was a major problem. It appears that the rate of complications in this study is acceptable and comparable with or favourable to other reported series. In spite of this, every effort should be made to reduce the operative morbidity as far as possible.

Oncogene patterns in breast and ovarian carcinomas.

Nineteen paraffin-embedded breast cancer tissue samples selected for long survival (more than 5 years) were analysed for detecting the amplification of the c-erbB-2 (Her-2/neu) oncogene by Polymerase Chain Reaction (PCR). Strong correlation was elucidated between c-erbB-2 amplification and survival; such correlation was also observed with histopathologic types and nuclear grading. Because of the similarity of the breast and ovarian cancer in the etiology of the diseases, amplification of c-erbB-2, c-myc and Ki-ras genes was examined in 32 ovarian carcinoma samples (stage I-IV). In ovarian carcinomas c-erbB-2 amplification occurred in 34% (11/32) of the fresh tumour samples, and correlation between amplification and clinical staging at P < 0.05 significance level was observed. Amplification of c-myc was detected in 9% (3/32) and none of the tumours showed amplification of Ki-ras.

Vaginal cytology and the human menopausal gonadotropin-test (HMG-cytohoromonal-test) in cases of gonadal dysgenesis.

Cytohormonal investigations and HMG-cytohormonal-test were carried out in 15 patients suffering from gonadal dysgenesis and the results were compared with the histology of the gonad, the karyotype and the clinical appearance. All patients were primary amenorrhoeic. According to the gonad histology and the phenotype the term "gonadal dysgenesis" was subdivided into Turner's syndrome, pure gonadal-dysgenesis and syndrome of ovarian hypoplasia. For the HMG-cytohormonal-test Humegon was administrated three times in weekly intervals (one amp. 75. i.u. in the first, two amp. in the second and three amp. in the third week). The gonadal response to Humegon was detected by vaginal cytology taken on the first, second, fourth and sixth days, after each injection of Humegon. Smears in patients with streak gonads irrespective of their phenotype were completely atrophic and did not change following Humegon administration. This finding seems to be characteristic and the HMG-cytohormonal-test is a simple way to diagnose the presence of the streak gonad. Cytohormonal patterns in the syndrome of ovarian hypoplasia accompanied by primary amenorrhoea consisted of mostly intermediate cells although superficial cells in five to 20 per cent and parabasal cells in five per cent also occurred. Following Humegon administration there were no or slight changes in the smears, much less marked than those in secondary ovarian failure.

The fate of the retained ovaries following radical hysterectomy.

UNLABELLED: The authors studied the function of the preserved ovaries following radical hysterectomy in 65 patients with early stage cervical carcinoma. The ovaries were not displaced and fixed out of the pelvis. Squamous cell carcinoma was diagnosed in 91 cases and adenocarcinoma in 19 cases. Histologic studies of the 110 ovaries removed from 45 patients revealed no metastatic disease. None of the 65 women suffered from recurrent disease. Ovarian function was evaluated by: 1) the presence or absence of postmenopausal symptoms; 2) basal body temperature charts; 3) blood tests for FSH, LH, progesterone, and prolactin; and 4) evaluation of the cervical and vaginal epithelium (vaginal smears). The diagnosis of ovarian failure was based on high levels of FSH (> 30 U/L) on at least three occasions. Basal body temperature studied in 90 cycles of 25 patients revealed various curves indicating occasional anovulatory cycles and luteal-phase deficiency which were confirmed by low serum levels of progesterone. Serum prolactin levels were within the normal range in all cases. Ovarian failure was diagnosed in two instances. Both occurred within three years of radical hysterectomy. Three of the six patients experienced unilateral ovarian cyst formation following surgery, the other three had subsequent unilateral salpingo-oophorectomy at 6, 11, and 24 months after radical hysterectomy. CONCLUSIONS: Preservation of the ovaries at the time of radical hysterectomy and lymphadenectomy does not seem to compromise patient care. Impaired function or failure of the retained ovaries, however, is not uncommon; close post-treatment surveillance is therefore important in terms not only of recurrent disease but of function of the ovaries as well.

The value of colposcopy in screening cervical carcinoma.

The value of colposcopy and cytology in screening CIN was analyzed in a retrospective study of 1,504 patients treated at the Department of Gynecologic Oncology, National Institute of Oncology, Budapest from 1980 to 1991. The majority (1,451) of the patients were admitted for histological confirmation of atypical colposcopic and/or cytologic findings, and 53 women were treated for cervical repair. All women underwent either cervical excision or conization. Cytologic and colposcopic findings were compared with the histological results. Sensitivity and specificity rates of cytology were 47% and 77%, respectively. The corresponding figures for colposcopy were 87% and 15% and for cytology and colposcopy together, 96% and 14%. The low sensitivity of cytology suggests that as many as 50% of CIN lesions may be overlooked if cytology alone is used for screening, i.e. in 50% of CIN associated with abnormal colposcopy the cytology was negative. We found 194 asymptomatic patients with carcinoma in situ, 40 with microinvasive and 8 with frank invasive carcinoma. This finding emphasizes the importance of cervical cancer screening. Our data suggest that, with colposcopy as a screening tool, the rate of false-negative cytology can be significantly reduced. Clinical implications of the "cytology-negative abnormal colposcopy and cytology-negative CIN" have yet to be determined. The major drawback of primary colposcopy is its low specificity with the consequence of high false-positive rate and over-treatment in a substantial number of cases. To overcome the problem of low specificity, further studies are required to identify those atypical colposcopic changes that most likely represent CIN--and high-grade CIN in particular.

Physique of patients with carcinoma of the female genital tract.

The authors carried out an investigation with a detailed anthropometric programme on 135 women suffering from different kinds of cancer: ovarian n = 35, endometrial n = 22, cervical n = 54, and vulvar/vagina n = 24. All patients were Hungarian and belonged to European ethnic groups. Their age varied between 25.6 and 85.0 years. Somatotype of the patients was estimated with the Heath-Carter anthropometric somatotyping method. Somatotype (endomorphy, mesomorphy, ectomorphy) of the patients with ovarian cancer was respectively: 6.8-5.3-1.0, patients with endometrial cancer 7.9-5.8-0.9, patients with cervical cancer 6.8-5.3-1.3, and patients with vulvar cancer 7.5-5.9-0.9. Based on variance analysis, there was no significant difference among subgroups at the p < 0.05 level. The patients in all four groups--in the overwhelming majority of cases--showed mesomorphic-endomorph forms, i.e., endomorphic elements dominated in their physique and mesomorphy (robusticity) was greater than ectomorphy (linearity).

A simplified version of the "Indiana pouch" technique for urinary diversion. Experience of the first 18 cases.

During the last 3 years, a modified technique of the continent urinary diversion, known as the "Indiana pouch" has been performed in 18 patients as part of pelvic exenteration. The narrowing of the ileum and/or the site of Bauchin valve was excluded from the procedure. In order to achieve anti reflux effect, ureters were implanted to the urinary reservoir by the "split cuff nipple" technique instead of tunnelling ureters. Sufficient urine continence and lack of urine reflux in the ureters indicated that satisfactory function could be achieved by the simplified technique. A quality of life questionnaire has suggested that most of our modified Indiana Pouch patients coped well. Operative technique, indications, operative results, and complications are discussed.

[Familial ovarian cancer syndrome]. / Családi petefészekrák syndroma.

This paper gives an overview of the familial ovarian cancer. Ovarian cancer prone families defined as two or more first or second degree relatives with ovarian cancer, are of clinical importance because first or second degree family members of affected women are at risk of developing ovarian cancer. These women need surveillance including prophylactic oophorectomy in those with increased risk. Women with hereditary ovarian cancer are at the greatest risk. Familial ovarian cancer studies are also important in terms of research. They provide the best hope of identifying a gene involved in the genesis of ovarian cancer. There is good evidence that such a gene is likely to be involved in the development of non-familial ovarian cancer as well. This might be a clue to understanding the biology of ovarian cancer. Therefore ovarian cancer prone families should be identified and, since familial ovarian cancer is rare, available details about affected and non-affected family members should be registered at least at national level. The author set up the Hungarian Registry for familial ovarian carcinoma at the National Institute of Oncology Budapest.

[Autoimmune ovarian inflammation]. / Autoimmun petefészek-gyulladás.

Autoimmune oophoritis, which is frequently associated with other autoimmune diseases including other endocrine organs (autoimmune polyglandular syndrome), may precede the associated diseases by several years. The clinical significance of this association has increasingly been emphasized. And, this should facilitate early diagnosis since early initiation of replacement therapy can be life-saving. Thus, a review article on this subject apparently is of interest not only for gynaecologists but for internists, general practitioners and others.

[Ovarian cancer and the surgeon's knife. Early cancer of the ovary]. / Petefészekrák és a sebészkés. Korai petefészekrák.

The surgical aspect of ovarian cancer, based on the author's personal experience upon several hundreds patients and on the literature data, has been reviewed. Primary laparotomy is the cornerstone of the management of early stage ovarian cancer. This should include removal of the tumour and staging laparotomy. Better understanding of the tumour biological behavior is important to make a firm decision on conservative surgery in young patients with unilateral tumour who desire preservation of fertility. Rutin second-look laparotomy does not seem to be indicated in early stage disease.

[Ovarian cancer and the surgical knife. Advanced ovarian cancer]. / Petefészekrák és a sebészkés. Elörehaladt petefészekrák.

Surgery of advanced ovarian carcinoma includes total abdominal hysterectomy, bilateral salpingo-oophorectomy, partial or total omental resection and removal as much secondaries as possible. Distinction between optimal and suboptimal debulking is important in terms of survival. This is based on the size of the diameter of the largest residual tumour following primary surgery (< 2 cm vs > 2 cm). The value of lymphadenectomy is still controversial. However, it should be explored in prospective studies. The role of second-look laparotomy in advanced ovarian carcinoma remains debatable. Secondary debulking appears to be beneficial only if it is followed by adjunctive chemotherapy.

[Should estrogen replacement therapy be applied in women with genital and breast cancer?]. / Adható-e hormonpótló kezelés a nöi nemiszervek és az emlök daganatainak eseteiben?

In this country, hormone replacement therapy (HRT) has been used more extensively in the last few years. The benefits of HRT in cardiovascular diseases, osteoporosis and quality of life has been well established. Breast cancer and endometrial carcinoma have been considered as contraindications for HRT. A reappraisal of this practice is necessary since we have no evidence that HRT may adversely influence the outcome of these tumours. Nevertheless, theoretically this is possible because the effect of estrogens on occult metastases in unknown. The relationship between replacement therapy and the uterine sarcomas is of particular concern. HRT is safe in patients successfully treated for carcinoma of the vulva, vagina, uterine cervix and in those with ovarian cancer. Experience suggests that the estrogen can also be used safely in women treated previously for endometrial cancer. As far as breast cancer is concerned it appears logical to discuss the risk-benefit considerations with our patients before embarking on using HRT. Consultation with a gynaecological oncologist prior to HRT in patients with endometrial and/or breast cancer is strongly recommended.