Nicholas Lambrou

The safety of incidental appendectomy at the time of abdominal hysterectomy

OBJECTIVE The purpose of this study was to assess the complication rates of incidental appendectomies in women who undergo benign gynecologic procedures. STUDY DESIGN This was a retrospective case-controlled study of patients who did (n=100 women) or did not (n=100 women) undergo incidental appendectomies at the time of an abdominal hysterectomy between June 1995 and January 2001. Information was abstracted from hospital and clinic records and a gynecologic oncology database. Data were obtained about age, body mass index, hypertension, diabetes mellitus, the number of days with nothing by mouth, the length of hospital stay, and postoperative complications (cellulitis, fever, ileus, pneumonia, thromboembolic disease). Data were analyzed with the use of two-sample t tests, Wilcoxon Rank sum tests, chi(2) tests, and multiple logistic regressions. RESULTS There was no difference in preoperative diagnosis or operative procedure for either group. The number of patients in the group that did have incidental appendectomy versus the group that did not have incidental appendectomy with additional procedures at the time of abdominal hysterectomy was bilateral salpingo-oophorectomy (66 vs 61 women), unilateral oophorectomy (19 vs 19 women), lysis of adhesions (9 vs 8 women), and others (12 vs 8 women). Compared with the group that did not have incidental appendectomy, the group that did have incidental appendectomy was younger (mean age+/-SD: 44+/-9.6 years vs 48+/-13.6 years, P=.02) and had a lower mean body mass index (26.1+/-6.0 kg/m(2) vs 29.8+/-8.9 kg/m(2), P=.0009). No significant differences were found between the two groups (the group that did have incidental appendectomy vs the group that did not have incidental appendectomy, respectively) with respect to the following postoperative complications: fever (40 vs 27 women), cellulitis (1 vs 2 women), wound collection (4 vs 6 women), wound dehiscence (1 vs 5 women), wound abscess (7 vs 6 women), ileus (3 vs 2 women), and urinary tract infection (4 vs 10 women). The mean length of hospital stay was significantly longer in the group that did have incidental appendectomy than in the group that did not have incidental appendectomy (3.6+/-1.52 days vs 3.1+/-1.1 days, P=.006). However, the difference was no longer significant when patients who were fed electively on the postoperative day 2 were excluded from the analysis (3.16+/-1.13 days vs 3.04+/-1.13 days, P=.507). Thirty-one percent of the histologic specimens were abnormal, with fibrous obliteration being most common, and there was one case of acute appendicitis. CONCLUSION An incidental appendectomy at the time of benign gynecologic procedures does not increase postoperative complication rates or length of hospital stay. The inclusion of incidental appendectomies in all abdominal hysterectomies could potentially decrease the morbidity and mortality rates because of appendicitis in elderly women.

Formation of functional neovagina with vertical rectus abdominis musculocutaneous (VRAM) flap after total pelvic exenteration.

Background:Pelvic exenteration may be the only curative option for women with recurrent pelvic malignancies. After total pelvic exenteration, the resultant perineal defect heals slowly if left to do so by secondary intention. Reconstruction with the vertical rectus abdominis musculocutaneous (VRAM) flap brings a generous bulk of healthy tissue into the defect, speeding recovery by facilitating primary healing. Methods:Six women underwent reconstruction of a neovagina using a vertical rectus abdominis musculocutaneous flap. All 6 had total pelvic exenteration for advanced gynecologic malignancy. Primary diagnosis was cervical carcinoma (n = 3), vulvar carcinoma (n = 1), nonsmall cell vaginal cancer (n = 1), and vaginal melanoma (n = 1). Four patients had received adjuvant radiotherapy preoperatively. Results:All flaps remained 100% viable postoperatively. There were no cases of fistula, infection, or bowel obstruction. Two patients died of cardiovascular arrest postoperatively. The 4 other patients report satisfaction with reconstruction. Three had vaginal intercourse with orgasm. Conclusion:The inferiorly based vertical rectus abdominis musculocutaneous flap is a dependable source of tissue for pelvic reconstruction and is the flap of choice in the Division of Plastic Surgery. In addition to facilitating healing, the VRAM flap (neovagina) improves a womans psychosocial well-being.

Papillary squamous cell carcinoma of the uterine cervix: an immunophenotypic appraisal of 12 cases

OBJECTIVE The objective was to evaluate the role of human papillomavirus (HPV) in the pathogenesis of papillary squamous cell carcinoma (PSCC) of the cervix and to determine cell proliferative activity and p53 abnormalities in these rare variants of cervical cancer. METHODS Twelve examples of PSCC of the cervix were diagnosed between 1990 and 1999. Formalin-fixed paraffin sections of each tumor were stained by immunoperoxidase method using antibodies to p53 gene product (CM-10) and Ki-67 (MIB-1). In situ hybridization for HPV DNA (ENZO) was used to detect specific sequences of DNA shared by most types of genital HPV, followed by confirmatory PCR analysis. The nuclear staining for Ki-67 was graded as minimal (<10% of cells), moderate (between 10 and 50% of cells), and high (>50% of cells). RESULTS Fifty-percent of the tumors showed presence of HPV DNA. Three tumors (25%) showed nuclear accumulation of p53. Moderate and high proliferative activity was observed in four and eight of tumors, respectively. Eight patients presented with stage IB1 tumor (67%), 3 with stage IA1 tumor (25%), and 1 with stage IIIA tumor (8%). Eleven patients (92%) were alive as of last contact with a mean follow-up of 34.2 months (range: 5 days to 84 months). CONCLUSION In this series of patient, PSCC of the uterine cervix had a low rate of HPV DNA in their genome and a low rate of p53 gene abnormality. These genotypic differences may explain the differences between the clinical behavior of PSCC and the common types of squamous cell carcinomas of the cervix.

High-grade squamous intraepithelial lesions

agement of cervical cancer lesions occurred as a result of Cervical cancer precursors appear to have increased in a greater understanding of the precursor’s pathogenesis. prevalence over the past 2 decades in the United States Advances in the understanding of the role of human and Western Europe.1 An increase in the incidence of papillomavirus infection in the various precursor lesions high-grade cervical cancer precursors began to be dehas led to a reevaluation and evolution in the pathologitected in the early 1980’s among white women under cal nomenclature. The primary system for nomenclature the age of 50 in the United States according to the used in the United States for cervical cytology is The National Cancer Institute’s Surveillance, Epidemiology, Bethesda System. The Bethesda System was originally and End Results (SEER) program.2 Currently, 1.5%–6% developed from a National Cancer Institute workshop of all cervical cytologic evaluations in the United States held in Bethesda, Maryland in 1988. Further refineand England result in defining a cervical cancer precurments were made in 1991, and most recently in 2001. sor. Wide variations exist, depending on the population Figure 1 outlines the new Bethesda System guidelines screened and the cytology laboratory being used.3,4 (www. Bethesda 2001.cancer.gov). An increased understanding of the natural history of

Candidate Gene in Predicting In Vivo Ovarian Cancer Response to Combination Therapy with Paraplatin and Paclitaxel

INTRODUCTION. Adverse drug reactions, due at least in part to interindividual variability in drug response, rank between the 4th and 6th leading causes of death in the U.S. The field of “pharmacogenetics” (the study of variability in drug response due to heredity), should help in reducing drug-caused morbidity and mortality[1]. The underlying genetics for the efficacy of the chemotherapeutic treatment of ovarian cancer is still unknown and subject to a high degree of uncertainty and interindividual variability[2]. In the present project, using a pharmacogenomic approach, we evaluate the patient response rates to primary chemotherapeutic treatment of ovarian cancer with combination of paclitaxel and the carboplatin agents. In an attempt to define the genetic determinants for this variability, we are conducting a pharmacogenomics study to predict response based on patient genomics[3].