loch B

Acetic acid visualization of the cervix: an alternative to cytologic screening.

Objective To investigate the value of acetic acid visualization of the cervix as an alternative to cytologic screening. Methods A prospective study was conducted in a squatter area in Cape Town, South Africa, on 2426 women who underwent speculum examination, naked-eye inspection of the cervix after application of acetic acid, and cytologic smear. The smears were stained and processed at the screening site. Patients with a positive reading after acetic acid or a smear indicating a high-grade squamous intraepithelial lesion (SIL) were referred for immediate colposcopy, biopsy, and when indicated, treatment by large loop excision of the transformation zone. Therefore, histology was obtained on all patients with a positive acetic acid test or a positive cytology. Results Seventy-six women with positive reactions to acetic acid. Among the 2350 women with negative reactions, 254 had positive cervical smears; only 11 of these had histologic high-grade SIL. In contrast, 20 of the 61 women with positive cytology and positive acetic acid test had high-grade SIL on histology. Therefore, the acetic acid reaction enabled the observer to detect 20 of the 31 women (64%) who exhibited a high-grade SIL both on cytology and histology. Conclusion In locations where access to cytopathology is limited, naked-eye visualization of the cervix after application of diluted acetic acid warrants consideration as an alternative in the detection of cervical premalignant lesions.

The use of concomitant chemotherapy and radiotherapy prior to surgery in advanced stage carcinoma of the vulva

Six cases of primary advanced squamous carcinoma of the vulva were treated with concomitant chemotherapy and radiotherapy (C + RT). In five patients it was given in preparation for surgery. The radiation was delivered to the whole pelvis in 10 equal daily fractions of either 2.0 or 2.5 Gy. Mitomycin C (10 mg/m2) was given on Day 1, and 5-fluorouracil (1,000 mg/m2) was given daily from Days 1 to 4, inclusive. All six patients had satisfactory early tumor response. Three patients received one course of C + RT and three were given two courses. One patient died suddenly of unknown causes 6 days after completing the C + RT. One patient with fixed groin nodes was treated with palliative intent. She maintained a complete local response but died 6 months later of liver metastases. The remaining four patients underwent surgery without healing complications and are alive with no evidence of disease at 1, 4, 14, and 26 months. In our experience vulval carcinomas can be reduced in size and extent by prior chemotherapy and radiotherapy and require less extensive surgery.

The value of cancer antigen-125 as a tumor marker in malignant germ cell tumors of the ovary

The value of cancer antigen-125 (CA-125) as a tumor marker for malignant germ cell tumors (MGCT) of the ovary was investigated and compared with the other recognized tumor markers (human chorionic gonadotrophin (hCG), alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA) and lactate dehydrogenase (LDH) isoenzymes. In the 10 months following June 1984, 4 new cases with MGCT and 1 patient with active disease on treatment were evaluated. In all cases prior to planned surgery the levels of CA-125 were significantly elevated. The serum values ranged from 154 to 617 U/ml (normal less than 20 U/ml). In 1 case (pure dysgerminoma) CA-125 was the only tumor marker. In 3 patients (2 mixed germ cell tumors and 1 immature teratoma) serum LDH (LD 1, 2, and 3) was elevated, and AFP was elevated in 1 of these. In the fifth case (mixed germ cell tumor), on treatment, serum AFP was used to monitor the disease. Four patients underwent cytoreductive surgery followed by combination chemotherapy. The changes in the serum levels of CA-125 paralleled those of the other tumor markers while on therapy. In our experience CA-125 is an invaluable indicator of the clinical status of the patient and could be a new tumor marker in patients with MGCT.

Gestational trophoblastic disease: The significance of vaginal metastases

Six patients with gestational trophoblastic disease whose presenting symptom was hemorrhage from vaginal metastases are discussed. The clinical features, management, and response to treatment are outlined and it is suggested that the presence of vaginal metastases should be regarded as a poor prognostic factor and an indication for multiple cytotoxic agent chemotherapy.

The role of cancer antigen 125 (CA 125) in the management of ovarian epithelial carcinomas

From June 1, 1984, to May 31, 1985, 98 cases of epithelial ovarian carcinomas were assessed and followed prospectively using a new murine monoclonal antibody OC 125 which detects the antigen CA 125. Serous tumors comprised 43.7% of cases, mucinous tumors 20.4%, endometrioid tumors 16%, and other epithelial tumors 19.4%. Tumors of low malignant potential and benign epithelial cystadenomas were not included. For this study the upper limit of normal for CA 125 was 20 U/ml. Thirty-six were new cases. In this group the initial CA 125 levels greater than 20 U/ml, greater than 35 U/ml, and greater than 65 U/ml were 97.2, 94.4, and 86.1%, respectively. When mucinous types were excluded the specificity rate did not change significantly. There was no significant difference in initial CA 125 levels between early stages I and II and late stages III and IV. No correlation between tumor bulk and the serum level of antigen was observed. The remaining 62 patients were being followed and in this group 50 were considered to be in remission. Six cases in the remission group had elevated CA 125 levels greater than 20 U/ml and 5 of these developed clinical recurrence. The correlation between the clinical status and concordant fluctuations in the serum levels of CA 125 in all histological types was 87.8 and 93.5% when 10 cases of mucinous tumors were excluded. The contingency coefficient was 0.746. Seven SLOs were performed. All had CA 125 levels less than 20 U/ml and the mean was 6.9 U/ml. Only 1 case was positive with microscopic disease. In our experience CA 125 was invaluable in the management and follow-up of patients with ovarian carcinoma especially for the early detection of recurrent disease and for the monitoring of patients on therapy.

Peutz‐Jeghers syndrome in association with adenoma malignum (minimal deviation adenocarcinoma) of the cervix. Case report

A 44-year-old woman was admitted to the Gynaecological Oncology and Radiotherapy unit of the Groote Schuur Hospital in Cape Town for persistent dysuria and a vaginal tumour. At the age of 16 the diagnosis of PeutzJeghers syndrome (PJS) had been made after she had presented with rectal bleeding and was found to have melanin pigmentation around the mouth and on her fingers. At the time she underwent surgery twice to relicvc intestinal obstruction due to duodenal intussusception. Two ycars later she had a bowel resection at which time duodenal hamartomatous polyps were found confirming the diagnosis of PJS. At the agc of 19 several anal polyps were removed. At the age of 40 she underwent a total abdominal. hysterectomy with bilateral salpingooophorectomy for menorrhagia. Histological examination of the cervix was thought to show adenosis. Three years later she presented to her gynaecologist with persistent dysuria, when the

Medroxyprogesterone acetate in non-metastatic gestational trophoblastic disease

Summary. The effect of medroxyprogesterone acetate (MPA: Depo‐Provera, Upjohn) as a contraceptive agent was assessed in 45 patients with non‐metastatic gestational trophoblastic disease and compared with 13 patients using hormonal and 26 patients using non‐hormonal methods of contraception. In the whole group of 84 patients 18 (21.4%) required chemotherapy. There was no statistically significant difference in the incidence of persistent trophoblastic disease between MPA (9/45) and the oral contraceptive group (2/13) and MPA and the non‐hormonal contraceptive groups (7/26).

Combined chemotherapy and radiotherapy in patients with advanced squamous carcinoma of the cervix (cis-platinum-bleomycin-vinblastine)

In a pilot study, nine patients with advanced carcinoma of the cervix were treated with combination chemotherapy including cis-platinum, vinblastine, and bleomycin repeated at 3-week intervals for three courses followed by radiotherapy. Only one patient showed a partial response (reduction of tumor size more than 50%). There were no complete responses. Five of the nine patients have died from the disease with a median survival time of 20 months. These findings suggest that this particular combination of chemotherapy with radiotherapy does not have a significant effect in patients with advanced stage carcinoma of the cervix.

Ultrasonography of pelvic masses

29 Romero R, Avila C, Brekus C et al. The role of systemic and intrauterine infection in preterm parturition in uterine contractility. In: Garfield R, editor. Mechanism of Control. Norwell, Massachusetts: Serono Symposia, 1990: 319-353. 30 Romero R, Quintero R, Nores J et al. Amniotic fluid white blood count: a rapid and simple test to diagnose microbial invasion of the amniotic cavity and predict preterm delivery. Am J Obstet Gynecol

Microhysteroscopy in evaluation of the endocervix in endometrial carcinoma

Microhysteroscopy (MH) was used for the assessment of endocervical involvement in patients with endometrial carcinoma. Between 1 July 1984 and 28 February 1985, fifteen cases were seen. Of these, nine patients had had fractional curettage and all were deemed to have endocervical involvement. As a result of the use of MH, five of these stage II cases were down-staged. The remaining four cases had their staging confirmed by MH and directed endocervical curettage. The six patients who had no initial endocervical assessment were found to have Stage I disease, using the MH alone. The MH findings were corroborated and confirmed on histological examination of the surgical specimens. MH should be the initial investigation in patients with suspected endometrial carcinoma and all patients with postmenopausal bleeding.