Misconceptions about routine colposcopy.

Colposcopy is practised in two ways: (1) to assess women with abnormal screening findings and/or clinically suspicious cervix (called referral colposcopy), and (2) as part of a routine gynaecological examination (referred to as routine colposcopy). There are several misconceptions about routine colposcopy probably reflecting the lack of experience in using routine colposcopy. Misconceptions include: routine colposcopy is screening colposcopy, it is time-consuming, expensive, a waste of time, and the training and maintaining of colposcopic expertise is probably not sufficient in this setting. Routine colposcopy, however, is not a screening tool, it is not screening colposcopy, but capable of identifying cervical precursors and cancer, and thereby reducing the false rates of cervical cancer screening (mainly cytology). Unlike referral colposcopy, routine colposcopy is an inexpensive and rapid procedure conducted as a part of a pelvic examination and has no, or minimal, discomfort that certainly does not exceed that of smear taking, neither is it associated with any psychological burden. Routine colposcopy allows gynaecologists to be convincingly sure in their findings; ensure women having normal epithelium; evaluate abnormalities in details (without biopsy) and counsel patients immediately to alleviate the psychological effects and prepare them for a possible abnormal smear; as well as help make a diagnosis of obscure lesions.

HE4--a novel promising serum marker in the diagnosis of ovarian carcinoma.

Biomarkers have a wide range of applications in the management of several cancers. To date serum markers have been the most extensively used biomarkers in everyday practice but few markers are elevated in preclinical or premalignant disease, limiting their importance for estimating risk or for screening. Human epididymis protein-4 (HE4) is a novel serum marker which is more sensitive in the prediction of risk of ovarian malignancy than CA125 alone in patients with a pelvic mass. HE4 in combination with CA125 appears to be an effective tool for the early detection of recurrence or monitoring the response to therapy. Risk of Ovarian Malignancy Algorithm, utilizing the dual marker combination of HE4 and CA125, can be used to stratify both postmenopausal and premenopausal women into high- and low-risk groups, allowing for an effective triage of women to appropriate institutions for their care. A review of HE4 and its feasibility as a novel diagnostic tool in the management of epithelial ovarian cancer is presented.

Tissue-based classification of HPV infections of the uterine cervix and vagina (mucosal HPV infections).

Terminology of HPV infections of the uterine cervix and vagina is somewhat confusing, with various terms having different meanings to different authors. This prompted us to revise the current terminology and propose a "tissue-based" classification of HPV infections of the cervix and vagina (mucosal HPV infections), which is based on histological appearance of the lesions and should be clear-cut in everyday practice of managing these patients. We hope the proposed nomenclature may overcome some of the confusion and controversy that exist in the current terminologies describing these lesions.

Physique of patients with carcinoma of the female genital tract.

The authors carried out an investigation with a detailed anthropometric programme on 135 women suffering from different kinds of cancer: ovarian n = 35, endometrial n = 22, cervical n = 54, and vulvar/vagina n = 24. All patients were Hungarian and belonged to European ethnic groups. Their age varied between 25.6 and 85.0 years. Somatotype of the patients was estimated with the Heath-Carter anthropometric somatotyping method. Somatotype (endomorphy, mesomorphy, ectomorphy) of the patients with ovarian cancer was respectively: 6.8-5.3-1.0, patients with endometrial cancer 7.9-5.8-0.9, patients with cervical cancer 6.8-5.3-1.3, and patients with vulvar cancer 7.5-5.9-0.9. Based on variance analysis, there was no significant difference among subgroups at the p < 0.05 level. The patients in all four groups--in the overwhelming majority of cases--showed mesomorphic-endomorph forms, i.e., endomorphic elements dominated in their physique and mesomorphy (robusticity) was greater than ectomorphy (linearity).

Molecular quantification and mapping of lymph-node micrometastases in cervical cancer.

BACKGROUND: A proportion of patients with cancer and lymph nodes negative on histology will develop recurrence. Reverse-transcriptase PCR (RT-PCR) is a highly sensitive method for detection of lymph-node micrometastases, but accurate quantitative assessment has been difficult. METHODS: We studied primary tumours and 156 lymph nodes from 32 patients with cervical cancer (stage IA2, IB1, and IB2) and 32 lymph nodes from nine patients with benign disease. A fully quantitative, real-time RT-PCR assay was used to document absolute copy numbers of the epithelial marker cytokeratin 19. Primers and probe were designed not to amplify either of the two cytokeratin 19 pseudogenes. FINDINGS: All primary tumours and histologically involved lymph nodes (six) had more than 106 copies of cytokeratin 19 mRNA per microg total RNA. Expression of cytokeratin 19 (up to 1.1 x 10(5) copies per microg RNA) was detected in 66 (44%) of 150 histologically uninvolved lymph nodes, and in nodes from 16 of 32 patients with cervical cancer. 15 of these 16 patients with evidence of micrometastases had the highest cytokeratin 19 transcription level in a first lymph-node drainage station (three obturator, six internal, and six external iliac node). Transcription of cytokeratin 19 was found at a low level in just one of 32 lymph nodes obtained from nine patients with benign disease. Median copy number of cytokeratin 19 transcription was significantly higher (>10(3) copies) in association with adverse prognostic features. INTERPRETATION: The results suggest that about 50% of early-stage cervical cancers shed tumour cells to the pelvic lymph nodes. The amount of cytokeratin 19 expression was related to clinicopathological features. Further studies are required to document the clinical implications of molecular micrometastases.

The value of colposcopy in screening cervical carcinoma.

The value of colposcopy and cytology in screening CIN was analyzed in a retrospective study of 1,504 patients treated at the Department of Gynecologic Oncology, National Institute of Oncology, Budapest from 1980 to 1991. The majority (1,451) of the patients were admitted for histological confirmation of atypical colposcopic and/or cytologic findings, and 53 women were treated for cervical repair. All women underwent either cervical excision or conization. Cytologic and colposcopic findings were compared with the histological results. Sensitivity and specificity rates of cytology were 47% and 77%, respectively. The corresponding figures for colposcopy were 87% and 15% and for cytology and colposcopy together, 96% and 14%. The low sensitivity of cytology suggests that as many as 50% of CIN lesions may be overlooked if cytology alone is used for screening, i.e. in 50% of CIN associated with abnormal colposcopy the cytology was negative. We found 194 asymptomatic patients with carcinoma in situ, 40 with microinvasive and 8 with frank invasive carcinoma. This finding emphasizes the importance of cervical cancer screening. Our data suggest that, with colposcopy as a screening tool, the rate of false-negative cytology can be significantly reduced. Clinical implications of the "cytology-negative abnormal colposcopy and cytology-negative CIN" have yet to be determined. The major drawback of primary colposcopy is its low specificity with the consequence of high false-positive rate and over-treatment in a substantial number of cases. To overcome the problem of low specificity, further studies are required to identify those atypical colposcopic changes that most likely represent CIN--and high-grade CIN in particular.

The fate of the retained ovaries following radical hysterectomy.

UNLABELLED: The authors studied the function of the preserved ovaries following radical hysterectomy in 65 patients with early stage cervical carcinoma. The ovaries were not displaced and fixed out of the pelvis. Squamous cell carcinoma was diagnosed in 91 cases and adenocarcinoma in 19 cases. Histologic studies of the 110 ovaries removed from 45 patients revealed no metastatic disease. None of the 65 women suffered from recurrent disease. Ovarian function was evaluated by: 1) the presence or absence of postmenopausal symptoms; 2) basal body temperature charts; 3) blood tests for FSH, LH, progesterone, and prolactin; and 4) evaluation of the cervical and vaginal epithelium (vaginal smears). The diagnosis of ovarian failure was based on high levels of FSH (> 30 U/L) on at least three occasions. Basal body temperature studied in 90 cycles of 25 patients revealed various curves indicating occasional anovulatory cycles and luteal-phase deficiency which were confirmed by low serum levels of progesterone. Serum prolactin levels were within the normal range in all cases. Ovarian failure was diagnosed in two instances. Both occurred within three years of radical hysterectomy. Three of the six patients experienced unilateral ovarian cyst formation following surgery, the other three had subsequent unilateral salpingo-oophorectomy at 6, 11, and 24 months after radical hysterectomy. CONCLUSIONS: Preservation of the ovaries at the time of radical hysterectomy and lymphadenectomy does not seem to compromise patient care. Impaired function or failure of the retained ovaries, however, is not uncommon; close post-treatment surveillance is therefore important in terms not only of recurrent disease but of function of the ovaries as well.

A multicenter study of recombinant human erythropoietin (epoetin alpha) in the management of anemia in cancer patients receiving chemotherapy.

Current evidence suggests that epoetin alpha administration is well tolerated and effective in the management of anemia of cancer and cancer chemotherapy. An open-label, multinational, non-comparative study was conducted in 215 cancer patients with anemia secondary to chemotherapy with platinum- or non-platinum-based combinations. Epoetin alpha was administered s.c. (150 IU/kg three times/week) for a planned period of 16 weeks. The response rate of epoetin alpha, defined as an increase in hemoglobin level of 2 g/dl or more from baseline, was 67%. The rate of response was not related to the chemotherapy regimen administered (platinum or non-platinum based). The percentage of patients transfused and the transfusion rate during epoetin alpha treatment were reduced. Transfusional need was eliminated in 64 (75%) of the 85 patients transfused before the study start, after 1 month of therapy. Quality of life, assessed using a visual analog scale, improved markedly in patients who experienced a hematological response. These patients also experienced a statistically significant (p < 0.0001) improvement in mean WHO performance score. These findings indicate that epoetin alpha is a well tolerated and effective agent which increases hemoglobin concentration and reduces transfusion requirements in anemic cancer patients receiving chemotherapy.

Allele loss from large regions of chromosome 17 is common only in certain histological subtypes of ovarian carcinomas.

Using a panel of ten polymorphic markers, we examined the frequency of loss of heterozygosity (LOH) on chromosome 17 in 55 sporadic ovarian tumours. LOH on 17p and 17q was observed to be 50% and 62% respectively. LOH at D17S5 was detected in 24/36 (67%) of malignant cases and in 19/43 (44%) at TP53; the marker D17S855 intragenic to the BRCA1 gene showed allele loss in 50% (20/40) cases. The data presented here suggest that loss of the whole chromosome 17 is a relatively frequent event (30%) in ovarian carcinomas and this observation is especially frequent for serous, transitional cell and anaplastic histological subtypes. Mucinous and endometrioid ovarian tumours showed only short interstitial deletions (4/11, 36%). The overall frequency of the short deletions was relatively low (7/43, 16%) in our panel of carcinomas. Amplification of c-erbB-2/neu oncogene was detected in 32% (11/34) of the carcinomas tested; the gene was amplified only in those histological subtypes in which high incidence of LOH on chromosome 17 was observed, and was associated with advanced stages of the disease. We conclude that different histological types of tumour may have different aetiological mechanisms, and tumour-suppressor genes on chromosome 17 might be associated specifically with serous and transitional cell ovarian carcinomas.

[Vaginal cancer in a woman with a family history of ovarian cancer]. / Hüvelyrák kialakulása egy családi petefészekrák terheltség miatt veszélyeztetett asszonyban.

The proband was referred to familial ovarian cancer surveillance because two of her sisters died of carcinoma of the ovary. Her third sister succumbed of cervical cancer and her brother had acute myeloblastic leukaemia. Her second brother is alive and healthy. None of her parents and their sibs suffered of malignant disease. The offspring of the proband's sibs are young and appear to be normal. During surveillance she developed a stage I vaginal cancer. Following preoperative brachytherapy she underwent a radical hysterectomy and bilateral salpingoophorectomy with pelvic lymphadenectomy, and she is free of disease during 2 years of follow-up. The authors are not aware of any similar case.

[Recombinant human erythropoietin in the treatment of anemic patients undergoing chemotherapy for cancer]. / Kemoterápiában részesülö vérszegény daganatos betegek kezelése rekombináns humán erythropoetinnel.

Twenty-seven anemic patients with malignant tumour who received chemotherapy were treated with recombinant human erythropoietin (r-HuEPO). The objective of this study was to evaluate the effect of r-huEPO on hematologic and quality of life parameters as well as on transfusion requirement in patients with anemia secondary to cancer and cyclic chemotherapy. Patient population was allocated into two groups based on the chemotherapeutic regimens: 1. cisplatin containing and 2, non cisplatin containing regimen. Using 2 g/dl increase in haemoglobin levels as the criteria for response, twenty women responded to r-huEPO treatment. The response was more marked in the cisplatin group. R-huEPO treatment saved transfusion in both groups. Again, less patients required transfusion among those treated with cisplatin. There was a marked improvement in the quality of life which was more pronounced in patients who responded to r-huEPO treatment and in those receiving non cisplatin chemotherapy. No serious adverse experiences occurred. In conclusion, two third of patients with anemia secondary to cancer and cyclic chemotherapy can be effectively treated with r-huEPO. R-huEPO treatment invariably saves transfusion and is highly effective in improving quality of life. Adverse reaction is exceptional.

[Should estrogen replacement therapy be applied in women with genital and breast cancer?]. / Adható-e hormonpótló kezelés a nöi nemiszervek és az emlök daganatainak eseteiben?

In this country, hormone replacement therapy (HRT) has been used more extensively in the last few years. The benefits of HRT in cardiovascular diseases, osteoporosis and quality of life has been well established. Breast cancer and endometrial carcinoma have been considered as contraindications for HRT. A reappraisal of this practice is necessary since we have no evidence that HRT may adversely influence the outcome of these tumours. Nevertheless, theoretically this is possible because the effect of estrogens on occult metastases in unknown. The relationship between replacement therapy and the uterine sarcomas is of particular concern. HRT is safe in patients successfully treated for carcinoma of the vulva, vagina, uterine cervix and in those with ovarian cancer. Experience suggests that the estrogen can also be used safely in women treated previously for endometrial cancer. As far as breast cancer is concerned it appears logical to discuss the risk-benefit considerations with our patients before embarking on using HRT. Consultation with a gynaecological oncologist prior to HRT in patients with endometrial and/or breast cancer is strongly recommended.

A simplified version of the "Indiana pouch" technique for urinary diversion. Experience of the first 18 cases.

During the last 3 years, a modified technique of the continent urinary diversion, known as the "Indiana pouch" has been performed in 18 patients as part of pelvic exenteration. The narrowing of the ileum and/or the site of Bauchin valve was excluded from the procedure. In order to achieve anti reflux effect, ureters were implanted to the urinary reservoir by the "split cuff nipple" technique instead of tunnelling ureters. Sufficient urine continence and lack of urine reflux in the ureters indicated that satisfactory function could be achieved by the simplified technique. A quality of life questionnaire has suggested that most of our modified Indiana Pouch patients coped well. Operative technique, indications, operative results, and complications are discussed.

[Experience with urinary conduit procedures]. / Az álhólyag (vizelet conduit) képzés módszereivel szerzett megfigyeléseink.

Between 1989 and 1993, 32 urinary conduit procedures were carried out at the Department of Gynaecological Oncology, National Institute of Oncology Budapest. Of these, 26 patients with pelvic tumour underwent total or anterior pelvic exenteration. The urinary conduit operation was performed in associated with radical hysterectomy due 2 vesico-urinary fistula in 2 patients, and as a palliative procedure in 4 instances (bladder fistula 2, bladder fistula and ureter occlusion 1 and bilateral ureteric obstruction 1). Mean age of the patients was 46, range 20-73 years. 23 patients underwent bladder replacement with "Bricker pouch" or ileal conduit, mostly in the first 2 years, and as a palliative procedure. Kock pouch was constructed in 3 and an Indiana pouch in 6 women. There was no intraoperative mortality. 3 patients died in the postoperative period, none of them due to complication of the urinary diversion procedure. Postoperative bleeding occurred in one ileal conduit that ceased spontaneously and in one Indiana pouch that required reoperation. Haematuria was a common finding in the first 3 to 5 days following surgery. Urinary leakage in the abdominal cavity lasting for 7 to 10 days postoperatively occurred in almost all instances in those who underwent a Bricker pouch. This did not require surgical intervention. 3 patients with Bricker pouch experienced pyelonephritis. Continent pouches are emptied by self-catheterization, 6-8 times daily. There were no other early complications. Techniques of urinary diversion are discussed.