Richard U. Levine

Endometrial polyps in postmenopausal patients receiving tamoxifen.

The histologic features of an endometrial polyp include irregular, often dilated glands, thick-walled blood vessels, and a fibrotic stroma. Such polyps may be responsive to some chemotherapeutic drugs that can exert hormonal effects. We report on endometrial polyps detected in three postmenopausal patients who were receiving tamoxifen for treatment of metastatic breast carcinoma. The clinical presentation in all cases was vaginal bleeding and all had documented uterine enlargement suggestive of an intrauterine malignancy. The polyps were large, measuring up to 9 cm in largest diameter. On histologic examination each polyp had extensive cystic glandular hyperplasia. In one case foci of atypical epithelial proliferation and predecidualization were noted. The atypical proliferation suggested a borderline neoplastic process and was strongly positive for carcinoembryonic antigen. These findings underscore the marked proliferative changes that can be induced in endometrial polyps in postmenopausal women receiving hormonally active chemotherapeutic agents.

Intraepithelial squamous lesions of the vulva: Biologic and histologic criteria for the distinction of condylomas from vulvar intraepithelial neoplasia

We reviewed 65 intraepithelial lesions of the vulva and distal vagina and compared the presence of koilocytosis, abnormal mitoses, and parabasal or basal nuclear enlargement with DNA microspectrophotometric distribution patterns and the presence of human papillomavirus antigen as determined by immunoperoxidase. Abnormal mitoses and cytologically atypical nuclear enlargement were specific predictors of aneuploidy and were reliable for distinguishing vulvar intraepithelial neoplasia (VIN) from condylomas. Koilocytosis was present in 100% of condylomas and 71% of aneuploid (VIN) lesions, but there were qualitative and quantitative differences in the distribution of koilocytic cells in the two classes of lesions. On the basis of these findings, criteria for distinguishing between VIN and condyloma are proposed.

Atypical immature metaplasia (AIM). A subset of human papilloma virus infection of the cervix

Atypical immature squamous metaplasia (AIM) is a poorly understood lesion with uncertain biological and clinical significance. This report reviews 170 cases of cervical condylomata and 60 cases of highgrade cervical intraepithelial neoplasia (CIN II/III); AIM was found in association with 34% of condylomata and 16% of high‐grade CIN. Thirty‐seven cases of AIM alone were reviewed and nearly all presented with a cytologic diagnosis of CIN I or condyloma and a colposcopic appearance of white epithelium with or without punctation and mosaic structure. The mean ages of patients with condylomata, AIM, CIN II, and CIN III were 27, 27, 32, and 37 years, respectively. By immunoperoxidase techniques 75% of condylomata, 16% of AIM, and 0% of CIN lesions were positive. The histologic criteria for the diagnosis of AIM and its morphologic distinction from CIN and relationship to condylomata, are outlined. AIM is a distinct histologic entity that shares similar epidemiologic, morphologic and biologic characteristics with condyloma. When AIM is found alone in biopsy material, careful correlation of cytology, colposcopy, and biopsy results should be performed and therapy should be based on the size and distribution of the lesion.

Vulvar intraepithelial neoplasia: Correlation of nuclear DNA content and the presence of a human papilloma virus (HPV) structural antigen

Immunoperoxidase localization of a human papilloma virus structural antigen (HPV) was attempted in 68 intraepithelial lesions of the vulva, 39 of which were analyzed for nuclear DNA content by microspectrophotometry. Overall, 5.9% (4/68) stained positive for HPV. Ninety percent (35/39) of the cases tested were aneuploid, and, of these, 2.8% (1/35) stained positive for HPV. In contrast, 50% (2/4) of the polyploid lesions were positive. Hence DNA microspectrophotometry and immunoperoxidase localization of HPV are useful coparameters for distinguishing wart virus infection (condylomata) from vulvar intraepithelial neoplasia. HPV is detected infrequently within aneuploid lesions, in keeping with the concept that epithelial maturation is required for virion assembly. Whether the HPV genome exists in a nonreplicative state within the aneuploid cell population is unknown.

Treatment of vaginal carcinoma in situ with the carbon dioxide laser

Thirty-six patients with vaginal intraepithelial neoplasia were treated with the carbon dioxide laser. More than half of the patients had grade 3 vaginal intraepithelial neoplasia (carcinoma in situ). The majority of patients were treated in a single session; six patients were treated twice, and two patients were treated three times. In 92% of the patients, the lesions were completely removed by the laser without significant side effects.

Human papilloma virus infection (condyloma) of the cervix and cervical intraepithelial neoplasia: A histopathologic and statistical analysis

Two hundred fifty consecutive cases previously diagnosed as advanced intraepithelial neoplasia (CIN 2 and CIN III) were reviewed and examined for the presence of coexisting condyloma. When the mean ages and age distributions were analyzed, there was a consistent shift of the age distribution to a younger age among women with CIN and condyloma as opposed to CIN alone. Furthermore, when the relationship between age and case accumulation was normalized from a curvilinear to a linear relationship, there were significant differences in the slope of the accumulation rate between cohorts of CIN III with and without condyloma. These differences suggest that the concordant observation of both lesions in a given patient is not a random process resulting from two independent events but rather indicates an underlying dependence between the two (i.e., condyloma and CIN). It cannot, however, be determined statistically whether the associated condyloma is directly responsible for the CIN lesion or hastens its transit time.

Cervical vascular malformation as a cause of antepartum and intrapartum bleeding in three diethylstilbestrol-exposed progeny

Adverse pregnancy outcome in diethylstilbestrol-exposed progeny has been described by many authors. These three cases demonstrate many of the features discussed in the literature as well as a previously unreported cause of antepartum and intrapartum bleeding: a cervical vascular malformation.

Evaluation of a method of hysteroscopy with the use of thirty per cent Dextran

Abstract A new method of fiberoptic hysteroscopy with the use of a 30 per cent Dextran solution to distend the uterine cavity has been evaluated on a series of 20 patients with routine gynecologic problems such as abnormal bleeding, fibroids, and infertility. The procedure, which is described, was uncomplicated. The technique proved to be a reliable diagnostic method. The potential applications of this endoscopic technique are discussed.

Hysteroscopic tubal sterilization: I. A preliminary report

Results with 17 patients treated by electrocautery coagulation of the interstitial endosalpinx to produce tubal blockage are reported. It was found that 30% Dextran was not a conductive solution so diathermic cauterization could be done under visual control with the uterus dilated with this solution. Initially, patients were given general anesthesia but 3 were treated with analgesia and local cervical block. Localization of tubal ostia was accomplished in all cases. An especially designed electrosurgical instrument was used. A 25% patient failure rate was shown by follow-up hysterosalpingograms after 3 months. In 1 case, an endometrial-tubal fistula was shown. This was closed by a subsequent cauterization. Pregnancy followed in 2 instances. After abortion by curettage, sterilization was done by the laparoscopic method for 1 of them. Subsequent repeat hysteroscopic cauterizations were done for some others. No morbidity resulted from the procedures. The 25% failure rate makes this approach only marginally acceptable as a means of tubal sterilization.

Colposcopic correlates of cervical papillomavirus infection

We compared the colposcopic and histologic features of 39 papillomavirus-related cervical lesions with their associated human papillomavirus type. Two thirds of the lesions contained human papillomavirus type 16-related deoxyribonucleic acid, and 69% of them were classified as cervical intraepithelial neoplasia I or II, in contrast to 92% of lesions containing human papillomavirus 6/11 deoxyribonucleic acid. On histologic examination, low-grade cervical intraepithelial neoplastic lesions tended to be sharply demarcated and have an uneven or granular surface contour. In contrast, high-grade lesions often had diffuse borders and were usually smooth in appearance. Both low- and high-grade lesions displayed variable degrees of whiteness, thickness, and papillomatous configurations. Patterns of coarse punctuation were more common in higher grade cervical intraepithelial neoplastic lesions and in those containing human papillomavirus 16. Predictably, the colposcopic features of lesions containing human papillomavirus 6/11 deoxyribonucleic acid sequences compared closely with those of low-grade cervical intraepithelial neoplasia. In contrast, human papillomavirus 16-associated cervical intraepithelial neoplasia exhibited a greater spectrum of colposcopic patterns, including those associated with condyloma and low- and high-grade cervical intraepithelial neoplastic lesions. We conclude that, although a portion of low- and high-grade cervical intraepithelial neoplastic lesions can be distinguished colposcopically, a significant number of lesions containing features of low-grade cervical intraepithelial neoplasia or condyloma contain human papillomavirus 16 deoxyribonucleic acid and cannot be distinguished from presumably innocuous human papillomavirus infections.