James Fanning

Paget's disease of the vulva: Prevalence of associated vulvar adenocarcinoma, invasive Paget's disease, and recurrence after surgical excision

OBJECTIVE Our aim was to determine the prevalence of associated vulvar adenocarcinoma, invasive Pagets disease, and recurrence of Pagets disease of the vulva. STUDY DESIGN A retrospective review of tumor and pathology registries at 8 institutions is presented. Patients with recurrent disease were excluded. Histologic slide review was performed. RESULTS The median age of the 100 patients was 70 years. The median duration of pruritus before surgery was 2 years. Thirty-four percent of patients experienced a recurrence at a median of 3 years. There was a 12% prevalence of invasive vulvar Pagets disease and a 4% prevalence of associated vulvar adenocarcinoma. One patient died of Pagets disease with associated vulvar adenocarcinoma. CONCLUSIONS Pagets disease of the vulva is rarely associated with an underlying vulvar adenocarcinoma or invasive Pagets disease, but there is a high recurrence rate.

Surgical staging and high dose rate brachytherapy for endometrial cancer: limiting external radiotherapy to node-positive tumors.

Objective To evaluate the efficacy and morbidity of surgical staging and high dose rate brachytherapy for women with stage I–IIIA endometrial cancer. Methods Sixty consecutive patients underwent surgical staging consisting of total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal cytology, bilateral pelvic lymphadenectomy, periaortic lymphadenectomy, and omentectomy. High dose rate brachytherapy was delivered post-operatively in three fractions for a total of 2100 cGy. Only patients with nodal metastasis received external radiotherapy. Results Twenty-two tumors (37%) were considered high-risk uterine disease because of deep invasion (stage IC), cervical involvement (stage II), positive peritoneal cytology (stage IIIA), or poor differentiation (grade 3). Lymph node metastases were detected in five patients. There was no surgical mortality, and morbidity from surgery and high dose rate brachytherapy was minimal. At a median follow-up of 3 years, there has been one recurrence. The conventional practice of postoperative external radiotherapy was altered in 23 of 60 patients (38%): 22 women with high-risk uterine factors did not receive external radiotherapy, and one patient with low-risk uterine factors (less than 50% myometrial invasion, grade 2) received external radiotherapy because of microscopic pelvic lymph node metastasis. Conclusion Surgical staging and high dose rate brachytherapy without external radiotherapy for stage I–IIIA endometrial cancer were associated with minimal morbidity and produced excellent survival

Frequency and yield of postoperative fever evaluation

OBJECTIVE: In women undergoing major gynecologic surgery, we wish to determine the frequency and yield of blood culture, urine culture, and chest X-ray evaluation of postoperative fever. METHODS: A retrospective review of 537 consecutive patients undergoing major gynecologic surgery was performed. In patients who developed postoperative fever, it was determined whether blood culture, urine culture, and/or chest X-ray were performed, and, if so, the frequency of positive results was evaluated. RESULTS: Two hundred eleven patients (39%) developed postoperative fever. Blood cultures were obtained in 77 of 211 (37%) febrile patients, urine cultures in 106 of 211 (50%) febrile patients, and chest X-ray in 54 of 211 (26%) febrile patients. Zero of 77 blood cultures were positive, 11 of 106 (10%) urine cultures were positive, and 5 of 54 (9%) chest X-rays were positive. Logistic regression revealed that late onset fever predicted for positive urine cultures and early onset fever and advanced age predicted for pneumonia. Eighty percent of patients with pneumonia were symptomatic. In 92% of patients with postoperative fever, no infections or pathologic process were diagnosed. CONCLUSION: Although postoperative fever is frequently evaluated by blood culture, urine culture, and chest X-ray, evaluation rarely yields positive results.

Loop electrosurgical excision procedure for partial upper vaginectomy

OBJECTIVES Partial upper vaginectomy consists of removal of the vaginal apex and is indicated for the diagnosis and treatment of vaginal intraepithelial neoplasia and recurrent cancer. We present a novel surgical approach to partial upper vaginectomy by use of the loop electrosurgical excision procedure. STUDY DESIGN A total of 15 consecutive patients with abnormal vaginal cytologic results were treated by the loop electrosurgical excision procedure for partial upper vaginectomy. After submucosal injection of local anesthetic, the loop electrode was used to resect the upper third of the vagina. An iodoform vaginal pack was placed for 24 hours. All patients with high-grade vaginal intraepithelial neoplasia received intravaginal 5-fluorouracil cream postoperatively. RESULTS The mean blood loss was 0 mL, and the mean surgical time was 30 minutes. A complication developed in 1 patient (7%). One case of invasive carcinoma was diagnosed. No recurrences have developed in any patients with vaginal intraepithelial neoplasia after hysterectomy. CONCLUSIONS The loop electrosurgical excision procedure for partial upper vaginectomy can be performed quickly, with minimal blood loss, minimal complications, and minimal recurrence of neoplasia, and it provides a histologic specimen for evaluation.

Peritoneal fluid urea nitrogen and creatinine reference values

OBJECTIVE To evaluate urea nitrogen and creatinine levels in peritoneal fluid. METHODS We prospectively evaluated 20 consecutive women having radical hysterectomy with lymphadenectomy. On postoperative days 2 and 3, serum, urine, and peritoneal fluid samples were tested for urea nitrogen and creatinine. Using power analysis we calculated an adequate sample size to be 16 patients. RESULTS The mean urea nitrogen was 11 mg/dL in serum, 11 mg/dL in peritoneal fluid, and 469 mg/dL in urine. The mean creatinine was .9 mg/dL in serum, 1.0 mg/dL in peritoneal fluid, and 141 mg/dL in urine. Urea nitrogen and creatinine values in peritoneal fluid and serum were essentially identical. Urine urea nitrogen and creatinine values were significantly greater than serum and peritoneal values (47 to 157 times greater) (P < .011). On postoperative days 2 and 3, serial levels of serum, peritoneal fluid, and urine urea nitrogen and creatinine in the same subject showed no significant variation (P ranging from .19 to .31). CONCLUSION Normal reference values of urea nitrogen and creatinine in peritoneal fluid are equivalent to serum values and significantly less than urine levels.

Yield of postoperative fever evaluation

Introduction: In women undergoing major gynecologic surgeries, we wish to determine the frequency and yield of blood cultures, urine cultures, and chest x-ray as part of postoperative fever evaluation.Methods: A retrospective review of 537 consecutive patients undergoing major gynecologic surgery. Postoperative fever was any temperature >/=38 degrees C. In patients who developed postoperative fever, it was determined if blood cultures, urine cultures, and chest x-rays were performed and how frequently these yielded positive results.Results: Two hundred eleven patients (39%) developed postoperative fever. Blood cultures were obtained in 77 of 211 (37%) febrile patients, urine cultures in 106 of 211 (50%) febrile patients, and chest x-rays in 54 of 211 (26%) febrile patients. Zero of 77 blood cultures were positive, 11 of 106 (10%) urine culture were positive, and 5 of 54 (9%) chest x-rays were positive. Logistic regression revealed that late onset fever predicted for positive urine cultures and early onset fever and advanced age predicted for pneumonia. Eighty percent of patients with pneumonia were symptomatic.Conclusion: Although postoperative fevers are routinely evaluated by blood cultures, urine cultures, and chest x-rays, they rarely yield positive results.

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DETECTION OF GENOMIC ALTERATIONS IN HUMAN CERVICAL CANCER BY TWO-DIMENSIONAL GEL ELECTROPHORESIS

Two‐dimensional gel electrophoresis was used to comprehensively scan the whole genome of 6 cervical intraepithelial neoplasia (CIN) lesions, 7 cervical squamous cell carcinomas, 1 cervical adenosquamous cell carcinoma, and 2 cervical adenocarcinomas for multiple genetic alterations, such as DNA amplification, chromosome deletion, loss of heterozygosity, and chromosome translocation, as compared with the paired normal tissues. DNA spot analysis of the genomic 2‐dimensional gels was performed by a computer color overlay system and by spot recognition software allowing for objective spot comparison and quantitation. Nine spots were found to be amplified in the cervical carcinomas while two amplified spots were detected in the CIN III lesions. Fourteen DNA spots were either reduced in their intensity or absent in cervical carcinomas as compared to their normal paired tissues. Reduction of intensity in 6 spots was observed in the 5 CIN III lesions. These genetic alterations may represent changes in cancer genes that are associated with human cervical carcinogenesis. Further characterization of these alterations may be significant to the understanding of cervical tumorigenesis and to the development of biomarkers for clinical trials in cancer chemoprevention. J. Cell. Biochem. 25S:41–48.