Robert S. Planner

Investigation of 100 consecutive negative cone biopsies

Objective To investigate the reasons for cone biopsies reported as not containing intraepithelial or invasive malignancy and thereby find ways to decrease their incidence.

Grapelike leiomyoma of the uterus

A 24-year-old nulliparous woman underwent laparotomy for a large pelvic mass. Grapelike tumor extending from the uterus into the broad ligaments and peritoneal cavity was found. A diagnosis of sarcoma appeared likely, but radical surgery was avoided when frozen sections indicated a histologically benign smooth muscle tumor.

Extrauterine malignant mixed müllerian tumor of primary peritoneal origin

&NA; The case of an extrauterine heterologous malignant mixed müllerian tumor (MMMT) of primary peritoneal origin occurring in a 63 yr old woman is presented. The tumor was a 19 cm, soft, friable mass arising from the serosa of the sigmoid colon and spreading to adjacent pelvic peritoneum. The uterus, tubes and ovaries were uninvolved. It was composed of sarcomatous areas showing cartilaginous and rhabdomyoblastic differentiation and sharply demarcated carcinomatous areas showing endometrioid and serous differentiation. This is the thirteenth reported case of an extragenital MMMT. It demonstrates the pluripotentiality of female pelvic peritoneum to differentiate into tumors resembling those of the genital tract.

Unusual variants of vaginal adenosis: A challenge for diagnosis and treatment

Two unusual cases of vaginal adenosis in non-diethylstilbestrol (DES)-exposed patients are presented. These cases created an initial difficulty in histological classification and exclusion of the diagnosis of adenocarcinoma. The first case presented a problem of atypical columnar epithelium with simple gland architecture, while the second showed a pseudoinfiltrative pattern of small glands, but without cytological atypia. A diagnosis of glandular dysplasia (atypical columnar epithelium) was finally made in the first case and vaginal adenosis with unusual architectural features in the second. The first patient was treated by excision and the second expectantly. Subsquently, neither patient has developed carcinoma. The spectrum of glandular changes in vaginal adenosis appears analogous to that of the cervix. Until the natural history of sufficient numbers of these variants of vaginal adenosis have been studied, the analogous cervical condition may serve as a guide to prognosis. The diagnosis of invasive adenocarcinoma should be made cautiously unless there are both architectural and cytological features of malignancy.

Cytology in the Follow-up of Cervical Cancer

OBJECTIVE To determine the value of cytology in the follow-up of cervical cancer. STUDY DESIGN The study group consisted of 230 patients with invasive cervical carcinoma who were followed for one to seven years. Forty-four patients developed recurrences or metastases. During this period, cytologic investigations involved 795 exfoliative smears from the cervix or vaginal vault, 10 fine needle aspirates and 5 fluids. RESULTS Thirty-three patients had positive or inconclusive cervical or vault smears that were histologically proven to be recurrences, and the other 11 patients had clinically obvious recurrences that were not smeared. Cytology first alerted the clinicians to recurrence in eight patients. Of 25 cervical or vault smears reported as malignant, 24 (96%) were histologically confirmed, and 1 showed radiation change on biopsy. In all 22 cases of smears reported as inconclusive, a biopsy followed, and in 9 (41%) of these, recurrence was demonstrated histologically. Inability to distinguish radiation change from recurrent malignancy was the chief cause of inconclusive smears. Five fluids and seven fine needle aspirates were diagnosed as malignant, saving patients an invasive diagnostic procedure. CONCLUSION Cytology is a useful, cost-effective, noninvasive and accurate investigation in the follow-up of cervical cancer.

Maximum effort in the management of ovarian cancer, including pelvic and para-aortic lymphadenectomy.

EDITORIAL COMMENT: There is no doubt that the competent gynaecological oncologist has marvellous skill at removing tumour in women with Stages 3 or 4 ovarian cancer ‐ in the very type of patient regarded as inoperable 10–30 years ago by general gynaecologists. Present‐day general surgeons presumably have the skill, but apparently not the will, to remove tumour in women with metastatic bowel cancer, for reasons not clear to the editor. Is it established fact that removing as much tumour as possible is a waste of time in women with extensive peritoneal metastases from bowel cancer; or does the general surgeon have a different therapeutic philosophy because a high proportion of his patients with bowel cancer have early stage disease, a state of affairs not enjoyed by those who operate on women with carcinoma of the ovary? Readers must be patient and await the publication of the 2 to 5‐year results of treatment of women with ovarian cancer managed by members of this oncology unit in Melbourne.

The Human Papillomavirus and the Lower Genital Tract

The role of human papillomavirus (HPV) in the aetiology of both preinvasive and invasive disease of the lower female genital tract and anus has become more clearly established. The evidence implicating HPV as the cause of dyspareunia, vulvodynia or pruritus is less convincing, and it is unlikely that subclinical vulvar HPV causes symptoms or warrants treatment . This editorial is intended to provide a brief review of HPV, its influence on the lower genital tract and its management.

Primary vaginal cancer after hysterectomy.

Objectives. We sought to examine the patients who developed vaginal cancer after prior hysterectomy and to determine whether any of these cancers could have been prevented. Methods. The records of patients treated with vaginal cancer over a 15‐year period in the Department of Gynecologic Oncology at the Mercy Hospital for Women were reviewed. Those patients who had developed a vaginal cancer after hysterectomy between 1980 and 1994 were identified. Results. A total of 1,511 primary gynecological cancers were treated between 1980 and 1994, and 23 (1.5%) were primary vaginal cancers. Of these 23 patients, 13 had had a prior hysterectomy (57%). Four of the 13 patients (31%) were asymptomatic and presented after routine vault smears, and 9 were symptomatic and were diagnosed after further investigation. All 13 patients had squamous cell cancers. Two patients had had a history of cervical intraepithelial neoplasia (CIN) grade 3 reported on cervical smear but not been accounted for, both cone biopsy and hysterectomy having found no histological abnormality. Conclusions. Primary vaginal cancer is uncommon. After hysterectomy, vaginal vault cytology should continue to be performed if high‐risk factors, such as history of lower genital tract neoplasia, are present. The two patients with unaccounted‐for CIN3 reported on Papanicolaou smear may have had undiagnosed vaginal intraepithelial neoplasia grade 3 (not CIN3) resulting in vaginal cancers 10 and 15 years later. Therefore, when colposcopy is being performed to investigate an abnormal Pap smear, the entire lower genital tract always should be examined.

Human papillomavirus transmission and carcinogenesis.

A simplistic approach to humanpapillomavirus (HPV) infection is to assume that sexual transmission is the sole means of acquiring the 14 plus HPV types found in the female genital tract. This assumption is based on the transmission of genital warts in sexually active adults but has not been verified for cases with subclinical infection identified by cytology, colposcopy, biopsy or DNA hybridization studies. While sexual transmission is an attractive and simple hypothesis, it can be seen from animal studies that many modes of transmission are possible. An alternative hypothesis could be put forward that we all carry various HPV types acquired either congenitally or from indirect spread. These viruses may remain latent until other cofactors are acquired or activate if immunological competence is compromised. The study of HPV has advanced dramatically over the past decade with 60 plus types identified by DNA hybridization and more recently subtypes have been defined. The advances made in molecular biology have supported a role of HPV in carcinogenesis, however questions relating to infectivity and natural history are severely restricted due to the lack of a culture system and the inability to infect an animal host, due to the species specificity of these viruses. Similarly, the typing of HPV based on DNA hybridization is still being refined and information on overall DNA sequence homology is insufficient to allow a clinically meaningful interpretation in terms of biological behaviour. Further developments in this area will need to focus at the level of papilloma virus genes to explain the cellular effects of these viruses (1). The transmission of HPV remains confused. While at least 14 of the 60 HPV types are commonly found in the genital tract, it is naive to assume sexual transmission is the only mode of spread. The main source of the virus is the infected patient, with infected cells being shed from the epithelium and disseminated in the environment. The length of time a virus can remain active is unknown however as inactivation occurs by heating above 55°C it is possible that the virus may remain active in the environment for a period of time at lower temperatures. This raises the possibility of both direct and indirect transmission. Animal studies support the complexity of papilloma virus transmission with autoinnoculation,