A subset of gestational trophoblastic disease characterized by abnormal chromosome 8 copy number detected by fluorescence in situ hybridization.

The present paper describes the results of research conducted to ascertain whether the report by Mark et al. [1], describing the concurrence of congenital trisomy 8 mosaicism and gestational trophoblastic disease (GTD) in a 42 year-old Gravida IV, Para IV patient was an isolated event. In contrast to other cases described in the literature, the patient described in Mark et al. [1] had no additional confounding chromosomal abnormalities other than trisomy 8. To the best of our knowledge, ours was the only reported case of constitutional trisomy 8 mosaicism associated with gestational trophoblastic disease, a rare gynecological disease entity. The question arises whether there exists a subset of patients with GTD characterized by an abnormal chromosome 8 copy number. The implicit hypothesis is that an abnormal number of chromosome 8 somehow predisposes to cancer. A pilot study of 10 cases of GTD was conducted using fluorescence in situ hybridization (FISH) and a commercial chromosome 8-specific alpha-satellite probe on formalin-fixed, paraffin-embedded patient tissues. Among eight informative cases successfully completed, two cases (25%) were found to be trisomic, when a cut-off point of 10% trisomic cells is adopted. Another two cases (25%) were found to be triploid. The results of our FISH study indicated that an abnormal chromosome 8 copy number found in Mark et al. [1] is unlikely to be an isolated event. Our data are consistent with the hypothesis that a subset of GTD indeed may exist which is characterized by more than two copies of chromosome 8. The present findings corroborate those recently found in breast, prostate, and other cancers.

Fluorescent in situ hybridization analysis of cervical smears. A pilot study of 20 cases.

The Papanicolaou smear has been established as a useful cytological screening tool that has greatly contributed to the reduction of cervical cancer related mortalities. This test, however, cannot reveal underlying genetic damage, i.e., numerical and structural chromosomal abnormalities that may predispose an individual to a future potentially life-threatening cervical neoplasm. An assay that has the ability to detect genetic abnormalities in interphase cervical mucosal cells will be a useful complement to the Papanicolaou smear on cytological preparations. The present project explores such a possibility using the technique of fluorescent in situ hybridization (FISH). The chromosome 8 specific alpha-satellite probe is initially used because of our past experience in the validation of this probe in various cancers. The applicability of this assay, however, is not restricted to the use of this particular probe. Data on our initial pilot study of 20 cases revealed that such an interphase FISH assay is indeed feasible as a potential future screening tool for cervical cancer.

Effect of intramuscular intraoperative pain medication on narcotic usage after laparoscopic cholecystectomy.

The purpose of this randomized, double-blind, clinical trial was to determine whether intraoperative, intramuscular (IM) injections of meperidine or ketorolac would improve postoperative pain relief in patients undergoing elective laparoscopic cholecystectomy. A total of 125 patients were entered into five study groups: 1) (N = 23) control placebo; 2) (N = 31) meperidine 100 mg IM intraoperative preprocedure; 3) (N = 20) meperidine 100 mg IM intraoperative postprocedure; 4) (N = 25) ketorolac tromethamine 60 mg IM intraoperative preprocedure; 5) (N = 26) ketorolac tromethamine 60 mg IM postprocedure. All groups were analyzed by comparing the amount of pain medication received in the recovery room, the time until first oral pain medication was requested, the overall amount of pain medication used in the first 24 hours, the percent requiring IM medication, and the pain score ratings from each group. There was decreased pain medication usage in the recovery room in all groups compared to control (P < 0.05). Group 4 had a longer painfree interval than meperidine groups or control. Both Groups 4 and 5 had decreased postoperative narcotic usage. Finally, the analogue pain scores showed that both ketorolac groups had significantly less postoperative pain compared to control, whereas the meperidine groups showed no improvement in postoperative pain relief. Intraoperative ketorolac given preprocedure or postprocedure significantly improved postoperative pain management and facilitated the transition to oral pain medication.

Fluorescent in situ hybridization assessment of chromosome copy number in buccal mucosal cells.

Sex chromatin (Barr body) analysis of buccal mucosal cells has been recognized for many years as an inexpensive, noninvasive and rapid means of sex determination. The conventional Barr body analysis using Papanicolaou stain was discontinued as a routine test because of its lack of reliability and its inability to detect mosaicism and other chromosomal abnormalities. With the advent of recombinant DNA technology and the availability of molecular probes, however, the value of this simple albeit obsolete test should be re-evaluated. The results of the authors' experience in optimizing a fluorescent in situ hybridization (FISH) assay on buccal mucosal cells are described. The utility and potential of this assay are explored and discussed.

Fluorescent in situ hybridization assessment of chromosome copy number in gestational trophoblastic disease.

The concurrence of congenital trisomy 8 mosaicism and gestational trophoblastic disease in a forty-two-year-old Gravida IV, Para IV female has been described. In contrast to other cases in the literature, this patient had no additional confounding chromosomal abnormalities other than trisomy 8. To the best of our knowledge, this was the only reported case of constitutional trisomy 8 mosaicism associated with gestational trophoblastic disease, a rare gynecological disease entity in and by itself. The present report describes fluorescent in situ hybridization (FISH) studies for assessing chromosome 8 copy number on various patient tissues. The results of the FISH studies are compared with each other and with the original cytogenetic studies. It is concluded that the overall frequency of trisomy 8 cells is lower in the FISH studies using archival material than in the original conventional cytogenetic studies. This is true for the uterus and lung tissues with a metastatic tumor. The possible reasons for the somewhat different frequencies found between conventional cytogenetics via GTG-banding and interphase cytogenetics via FISH are discussed.

Constitutional trisomy 8 mosaicism and gestational trophoblastic disease.

Concurrence of congenital trisomy 8 mosaicism and gestational trophoblastic disease in a 42-year-old gravida IV, para IV female is described in the present report. In contrast to other cases described in the literature, our patient had no known additional confounding chromosomal abnormalities other than trisomy 8. The finding of trisomy 8 mosaicism in yet another type of cancer provides further support for the hypothesis of an increased predisposition to cancer in tissues with constitutional genomic imbalance, which can manifest itself as numerical chromosomal abnormalities (e.g., trisomies) or structural chromosomal abnormalities (e.g., translocations). To the best of our knowledge, this is the only report in the English literature of constitutional trisomy 8 mosaicism associated with gestational trophoblastic disease, a rare gynecologic disease entity in itself.

Laparoscopic appendectomy for acute appendicitis: is there really any benefit?

Laparoscopic appendectomy is emerging as a popular treatment modality for acute appendicitis. Although claims have been made to potential superiority over traditional appendectomy, comparisons of operative difficulty, hospital stay, hospital costs, complication rates, postoperative pain, and convalescence have not been well studied. Two hundred consecutive patients presenting with signs and symptoms of acute appendicitis underwent appendectomy. Traditional appendectomy was employed in 101 patients, while 99 underwent laparoscopy. Successful laparoscopic appendectomy was possible in 89 patients who were compared with the 101 patients with traditional appendectomy. There were two pregnant patients with appendicitis in each group. The incidence of acute appendicitis was 72 per cent for traditional appendectomy and 74 per cent for laparoscopic appendectomy. Operating time was significantly longer with laparoscopic appendectomy (60.1 vs 45.4 minutes, P = 0.0001). This was reflected in higher (although not significant) hospital costs ($8,683 vs $6,213). Post-op hospital stay was shorter for laparoscopic appendectomy (2.7 vs 3.8 days, P = 0.001). Complication rates were no different between the two groups. Post-op pain, as evaluated by a patient grading scale, was less for laparoscopic appendectomies up to the third post-op week (P = 0.003). The amount of IM pain medication was greater with traditional appendectomy (P = 0.009). Convalescence was significantly shorter with laparoscopic appendectomy as measured by: 1) return to normal household activity (7.8 vs 13.2 days, P = 0.016), 2) returned ability to exercise (19.7 vs 29.0 days, P = 0.009), 3) patient feeling well enough to return to work (14.1 vs 19.2 days, P = 0.032), and 4) actual return to work (15.4 vs 20.5 days, P = 0.038).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of results of KTP/532 laser versus monopolar electrosurgical dissection in laparoscopic cholecystectomy.

A total of 641 laparoscopic cholecystectomies performed between January 1, 1991 and December 31, 1991 were reviewed to compare the results of Potassium Titanyl Phosphate (KTP/532) laser versus monopolar electrosurgery in laparoscopic cholecystectomy. KTP laser dissection was used alone in 199 cases (31%), and monopolar cautery was used in 442 (69%). During this same time period, 41 additional procedures were excluded because of conversion to open cholecystectomy. Procedures in which both modalities (N = 24) were used were also excluded from the study. Modality choice was dependent upon operating surgeon's preference. Data were analyzed with student t-test, chi-square with Yates correction, stepwise linear regression analysis, and correlation matrices. Five (2.5%) patients had five major complications when KTP laser dissection was used and 34 (7.7%) patients had 42 major complications when monopolar electrosurgical dissection was used (p < 0.05). Postoperative hospital stay with the KTP/532 laser dissection group was 1.4 +/- 0.06 days and for the monopolar electrosurgical dissection group it was 1.7 +/- 0.08 days (p < 0.05). The duration of the procedures was identical with either modality. The use of the KTP laser for dissection of the gallbladder during laparoscopic cholecystectomy may be a safer procedure with significantly decreased complication rates and savings in length of hospital stay. Although initially a more expensive procedure, the savings in length of hospital stay and treatment of complications may offset the initial expenditure and be worthwhile.

Fournier's gangrene: historic (1764-1978) versus contemporary (1979-1988) differences in etiology and clinical importance.

Experience with 11 cases of Fournier's gangrene during the decade 1979-1988, prompted this review of the English language literature to determine whether there have been changes in demography, etiology, and outcome, as compared to cases dating to 1763. All cases were evaluated according to age, sex, bacteriology, etiology, and outcome. In the decade 1979-1988, 449 cases were reported. The average age of the patients was 49.8 years; with 14 per cent occurring in females. Synergistic polymicrobial infections were present in all cases. The most commonly reported etiologies were colorectal (33%), idiopathic (26%), and genitourinary (21%). Mortality associated with colorectal etiology was highest (33%, p < 0.05). Female mortality (49%) was not significantly greater than male mortality (17%), when obstetrical etiology was excluded. Overall mortality was 22%. Comparison with 386 cases of Fournier's gangrene reported between 1763 and 1978 reveals that the mean age of patients remains relatively low, and males continue to predominate. The pathophysiologic aspects of this disease appear similar in both sexes. The mortality rate from colorectal sources is significantly greater than from other common causes. Neither the introduction of antibiotics nor the development of newer ones has reduced mortality significantly. In spite of newer diagnostic techniques, the etiology remains unclear in over one-fourth of cases.

Laparoscopic Janeway gastrostomy utilizing an endoscopic stapling device.

Percutaneous endoscopic gastrostomy (PEG) though generally considered the method of choice, is not suitable for all patients requiring gastrostomies. Previously the only alternative was open gastrostomy. With the recent growth and development of laparoscopic instrumentation new less invasive procedures have been developed. We present a new method of performing a Janeway gastrostomy using an endoscopic stapling device, and discuss some of its theoretical and practical usage in selected patients in reference to the literature on PEGs and open gastrostomies.

Clinical characteristics of placental site trophoblastic tumor (PSTT).

Placental site trophoblastic tumor (PSTT) has been demonstrated to be a rare variant of gestational trophoblastic disease, with only 43 cases of this disorder having been reported in the English language literature since 1976. It is associated with a 20% mortality rate, occurs in young women, is very resistant to standard trophoblastic disease chemotherapy, and is generally treated by hysterectomy. This report describes an additional 5 cases of PSTT, two of whom died of their disease. It aims to clarify the varied clinical characteristics of the condition through a comparative analysis of these patients with those previously reported. Specific factors in the analysis include age, mitotic count, presence of marker hormones, preceding gestational situation, cause of death, survival time from diagnosis, tumor karyotype, and treatment. The study suggests that a preceding term pregnancy, a high mitotic ratio, and an older age group may be associated with a higher mortality rate. It also supports the premise that some patients, with a low mitotic ratio and other favorable histologic features, may be treated conservatively with curettage and very careful follow-up monitoring if they wish to preserve reproductive potential.

Intraepithelial neoplasia of the neovagina.

Patients who require construction of a neovagina provide an opportunity for researchers to study some of the possible factors that cause vaginal neoplasia. Intraepithelial neoplastic changes occurring in the neovagina, remote from the graft margins, cannot be attributed to preexisting disease in the vaginal site. Such changes are unlikely to represent an expression of the oncogenic potential of the transplanted tissue. The most likely cause of these changes is the presence of a local carcinogenic environmental factor. Two cases are presented to demonstrate and support this thesis. The treatment prescribed, local excision in one case and application of topical 5-fluorouracil in the other case, resulted in disease-free intervals in excess of eight years for both patients.

The use of nitrogen mustard in the treatment of intractable pelvic pain.

Substantial relief of discomfort may be anticipated by most patients suffering from pelvic and lower-extremity pain who are treated by arterial infusion of nitrogen mustard. Seventy-three patients with intractable pain secondary to malignancy arising in the pelvis received 83 percutaneous pelvic arterial infusions of this drug. Sixty infusions (72%) resulted in marked relief from pain for periods averaging 6-8 weeks. Advantages of the procedure are low toxicity, relative simplicity and availability of technique, and an acceptable rate of complications with minimal morbidity. Patients experiencing satisfactory results may expect significant relief from a second infusion for recurrent pain. The most rewarding result is the freedom from the cyclic return of pain characterized by oral and intramuscular analgesic therapy. Little or no relief can be expected in patients with pain caused by compression fractures of the vertebrae, or where the tumor burden is so great that adequate perfusion of the involved nerves is not possible. One should consider this procedure for controlling pain before resorting to the more dangerous and potentially disabling techniques of spinal cordotomy or intrathecal alcohol injection.

Arterial infusion of nitrogen mustard in the treatment of intractable pelvic pain of malignant origin.

Sixty-two patients with intractable pelvic pain secondary to malignancy arising in the pelvis received a total of 72 percutaneous retrograde arterial infusions with nitrogen mustard. Fifty-three (74%) injections resulted in marked relief of pain for an average period of six to eight weeks. Five (7%) produced no pain relief. Toxicity was mild. There were two severe complications and no deaths related to the procedure or the drug in this study. Percutaneous retrograde arterial infusion with nitrogen mustard is suggested as the preferred procedure in the attempt to control pelvic pain caused by malignancy, before resorting to spinal cordotomy or intrathecal alcohol injection.

Uterine choriocarcinoma fourteen years following bilateral tubal ligation.

A patient who developed choriocarcinoma of the uterus 14 years after bilateral tubal ligation and resection is presented. Non-patency of the fallopian tubes was demonstrated radiologically. The various mechanisms of occurrence of the clinical picture are discussed. Activation of dormant chorionic cells present since the patient's last known pregnancy (1960) appears to be the most probable explanation for the origin of the choriocarcinoma.