Villoglandular adenocarcinoma of the cervix recurrent in an episiotomy scar: a case report in a 32-year-old female.

Cervical cancer during pregnancy is rare, occurring in approximately 3% of cervical cancer cases. Considerable controversy exists as to the long-term prognosis of patients diagnosed during pregnancy. A 32-year-old female presented with vaginal spotting in April 1998. A prenatal smear in December 1996 revealed atypical glandular cells of undetermined significance. A sterile speculum exam in April 1997 at 31-week gestational age revealed a polyp on the anterior lip of the cervix, pathology consistent with a well-differentiated villoglandular adenocarcinoma. In August 1997, the patient underwent a radical hysterectomy with pelvic/para-aortic lymphadenectomy. In April 2001, she represented with nodular perineal mass in the episiotomy incision. She received preoperative radiotherapy with a near-complete response and remained without disease for >10 months. It appears that a less radical procedure can offer significant therapeutic value. Preoperative radiotherapy proved effective at achieving a near-complete response. The patient underwent a wide local excision of the perineal area with resultant negative margins.

Hormonal and barrier contraception and risk of upper genital tract disease in the PID Evaluation and Clinical Health (PEACH) study.

OBJECTIVE: Among women diagnosed with pelvic inflammatory disease, we examined the associations between hormonal or barrier methods of contraception and upper genital tract infection or inflammation. METHODS: Participants were 563 patients from a treatment trial for pelvic inflammatory disease. All had pelvic pain; pelvic organ tenderness; and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. Contraceptive use within the prior 4 weeks was compared among women with baseline upper genital tract gonorrhea or chlamydia, women with endometritis without upper genital tract gonorrhea or chlamydia, and women with neither upper genital tract gonorrhea or chlamydia nor endometritis. RESULTS: Inconsistent condom use was significantly and independently associated with a 2 to 3 times elevated risk for upper genital tract infection. Upper genital tract gonorrhea or chlamydia was not significantly associated with use of oral contraceptives, use of medroxyprogesterone, condoms used consistently, nor other barrier methods. CONCLUSION: No hormonal or barrier contraceptive method was related to a reduction in upper genital tract disease among women with clinical pelvic inflammatory diseases.

Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study.

BACKGROUND: Douching has been related to risk of pelvic inflammatory disease (PID). GOAL: To examine the association between douching and PID in a large, multicenter, clinical trial of PID after adjustment for race/ethnicity. STUDY DESIGN: Interviews were conducted with 654 women who had signs and symptoms of PID. Vaginal Gram stains and upper genital tract pathology/cultures were obtained from all the women. Women with evidence of plasma cell endometritis and/or gonococcal or chlamydial upper genital tract infections were compared with women who had neither endometritis nor upper genital tract infection. RESULTS: Women with endometritis or upper genital tract infection were more likely to have douched more than once a month or within 6 days of enrollment than women who never douched. These associations remained after adjustment for confounding factors, after analysis of black women only; and among women with normal or intermediate vaginal flora but not bacterial vaginosis. CONCLUSION: Among a predominantly black group of women with clinical PID, frequent and recent douching was associated with endometritis and upper genital tract infection.

Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease.

OBJECTIVE: Careful detection and treatment of pelvic inflammatory disease are essential for the prevention of adverse sequelae. The purpose of this study was to evaluate the diagnostic test characteristics of clinical criteria for the diagnosis of pelvic inflammatory disease. STUDY DESIGN: We performed a cross-sectional analysis of the baseline characteristics of 651 patients enrolled in a multicenter randomized treatment trial for pelvic inflammatory disease. Clinical and laboratory findings were recorded for all patients, and endometrial sampling was performed. We calculated sensitivity and specificity and performed receiver operating characteristic curve analysis and multivariate logistic regression, using histologic endometritis as the criterion standard. RESULTS: The minimal criteria for pelvic inflammatory disease, as recommended by the Centers for Disease Control and Prevention, had a sensitivity of 83%, in comparison with a 95% sensitivity for adnexal tenderness (P =.001). Of the supportive clinical criteria, the finding most highly associated with endometritis was a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae (adjusted odds ratio, 4.3; 95% confidence interval, 2.89--6.63). A multivariate logistic regression model indicated that combinations of criteria significantly improve the prediction of endometritis. CONCLUSION: Sensitivity can be maximized by using the presence of adnexal tenderness as a minimal criterion for the diagnosis of pelvic inflammatory disease, and supportive criteria are helpful in estimating the probability of endometritis.

Factors predicting upper genital tract inflammation among women with lower genital tract infection.

We sought to identify factors that discriminate between women with a lower genital tract infection and women with a lower genital tract infection and endometritis. This study enrolled women at risk for or having a lower genital tract infection with Chlamydia trachomatis or Neisseria gonorrhoeae and measured behavioral and clinical factors. Women were identified through contact tracing of male partners, presentation with cervicitis, or presentation with symptoms of pelvic inflammatory disease and classified as (1) having a lower genital tract infection without endometritis, (2) having a lower genital tract infection with endometritis, (3) having no lower genital tract infection with endometritis, and (4) having neither a lower genital tract infection nor endometritis. The primary comparison was between women having a lower genital tract infection without endometritis to women having a lower genital tract infection and endometritis. Women with a lower genital tract infection and endometritis were older and reported a history of more sexually transmitted diseases (70.0% vs. 56.7%), abdominal pain (82.2% vs. 60.0%), and use of barrier methods of contraception (28.9% vs. 8.6%) than women with a lower genital tract infection alone. The regression model found that women with a lower genital tract infection and endometritis were 7.1 times (95% CI = 2.2-23.0) more likely to report abdominal pain and 4.6 times (95% CI = 1.5-14.9) more likely to use barrier methods of contraception than women with a lower genital tract infection alone. These results suggest that behavioral factors, in addition to symptoms, can be used to identify women with and without upper genital tract involvement.

Lactating adenoma: US features and literature review.

PURPOSE: To describe the ultrasonographic (US) features of adenoma in a lactating breast. MATERIALS AND METHODS: The US scans of 11 lactating adenomas in nine patients aged 25-36 years examined in 1991-1996 were retrospectively reviewed. In all lesions, diagnoses were cytologically or histologically proved after US-guided fine-needle aspiration biopsy (eight lesions) or core biopsy (three lesions). Six patients were lactating, and three patients were in the third trimester of pregnancy. The US features analyzed were shape, orientation to the chest wall, border characteristics, echogenicity, homogeneity, enhancement or shadowing, and depth within the breast. RESULTS: Most lesions had benign US features such as ovoid shape with the long axis parallel to the chest wall (10 of 11), well-defined margins (eight of 11), homogeneous echotexture (eight of 11), and posterior acoustic enhancement (10 of 11). Four lesions had US features that resembled malignant lesions, such as irregular margins, heterogeneous echotexture, and posterior acoustic shadowing. CONCLUSION: The US features, although generally benign, are not specific. Tissue sampling with fine-needle aspiration biopsy is recommended. Core biopsy is necessary if a diagnosis cannot be made with the aspirate but is not performed initially because of the possibility of milk fistula formation.

Oral contraception and the recognition of endometritis.

OBJECTIVE: Oral contraceptive use has been associated with a lower risk of symptomatic pelvic inflammatory disease but a higher risk of chlamydial cervicitis. To explain these seemingly contradictory findings, we asked whether oral contraceptive use was more common among women with unrecognized endometritis than among women with recognized endometritis. STUDY DESIGN: A multicenter case-control study was performed. Women without signs of pelvic inflammatory disease were ascertained through contact tracing of partners with sexually transmitted diseases or through presentation with cervicitis. Women with symptomatic pelvic inflammatory disease met a set of standard clinical criteria. We compared the 43 cases without signs of pelvic inflammatory disease but with endometritis ("unrecognized endometritis") with the 111 controls with recognized pelvic inflammatory disease and endometritis ("recognized endometritis"). RESULTS: Women with unrecognized endometritis were 4.3 times (95% confidence interval 1.6 to 11.7) more likely than women with recognized endometritis to use oral contraceptives. CONCLUSION: Future studies need to fully characterize the risks and benefits of oral contraceptives in relation to sexually transmitted diseases.

Interferon-gamma and interleukin-5 production by mice in response to genital infection by the mouse pneumonitis agent of Chlamydia trachomatis.

BACKGROUND AND OBJECTIVES: Mice sensitized with a chlamydial detergent extract and then genitally infected by Chlamydia trachomatis have increased genital inflammation characterized by elevated eosinophils, but do not have increased protective immunity. In contrast, mice infected previously by C. trachomatis show strong protective immunity. The authors studied interferon-gamma levels (associated with protective immunity) and interleukin-5 levels (the major cytokine responsible for eosinophilia). GOALS: To evaluate protective and nonprotective immune responses to chlamydial infection. STUDY DESIGN: The authors examined interferon-gamma and interleukin-5 levels in the genitalia during chlamydial genital infection among three groups of mice: extract-sensitized, sham-sensitized, and infected previously. RESULTS: Interferon-gamma levels peaked between 24 and 72 hours after chlamydial infection and then declined among all groups of mice. Overall, interleukin-5 levels increased throughout infection. Interleukin-5 levels apparently continued to increase over the 5-week period after primary infection. CONCLUSIONS: Increased interferon-gamma levels were associated with an early response to chlamydial genital infection. Increased interleukin-5 levels were associated with a more persistent immune response.

p53, retinoblastoma gene product, and cyclin protein expression in human papillomavirus virus DNA-positive cervical intraepithelial neoplasia and invasive cancer.

Human papillomavirus interacts with cyclin protein and tumor suppressor genes, p53, and retinoblastoma gene (Rb). Expression of these gene products was examined in 69 formalin-fixed, paraffin-embedded cervical biopsies by immunohistochemistry utilizing antibodies against p53, Rb, and proliferating cell nuclear antigen (PCNA) and by human papillomavirus DNA in-situ hybridization assays. Samples selected for this study included 27 normal/reactive atypia cases that were all human papillomavirus DNA in-situ hybridization negative, 37 cervical intraepithelial neoplasia (CIN) lesions, and 5 invasive carcinomas. The CIN and invasive carcinoma cases were all human papillomavirus DNA in-situ hybridization positive. p53 protein expression was detected in approximately one-third of the reactive atypia and CIN lesions and in 60% of invasive cancers. Neither the amount or the location of p53 staining was correlated with the histologic diagnosis. Rb staining was more frequently found in the CIN/invasive carcinoma cases compared to the normal/reactive atypia samples (39/42 [93%] versus 21/27 [78%], respectively; P < 0.05 by chi 2. PCNA staining was detected in virtually all samples tested. However, the location of both PCNA and Rb staining differed when the normal/reactive atypia cases were compared to the CIN cases. Only 10% of the former group demonstrated Rb staining throughout the basal two-thirds layer or full thickness of the epithelium compared with 65% of the latter group (P < 0.001 by chi2). Likewise, PCNA staining of the basal two-thirds or full-thickness of the epithelium was found in only 58% of normal/reactive atypia cases, but in 97% of the CIN group (P < 0.001). Our results suggest that the location of Rb and PCNA staining is quite different between normal/reactive atypia cervical biopsies and CIN lesions.

Interval between menarche and first sexual intercourse, related to risk of human papillomavirus infection.

The purpose of this investigation was to study the occurrence of human papillomavirus (HPV) infection in relation to the interval between menarche and first intercourse. Two hundred eight subjects, aged 13 to 21 years, were recruited from an ambulatory adolescent clinic. Patients were excluded if they had a history of genital warts or an abnormal Papanicolaou smear. All subjects completed a self-administered questionnaire regarding demographics and their menstrual, sexual, and contraceptive histories. HPV infection was determined by in situ hybridization or changes consistent with HPV on a Papanicolaou smear, or both. The prevalence of HPV infection was 19.2%. The average interval between menarche and onset of sexual activity was 26.6 months for those who were found to have HPV infection compared with 35.7 months for those whose test results were negative (p = 0.02). First sexual intercourse within 18 months of menarche was associated with a significant elevation of risk of HPV infection, in comparison with that in adolescents who postpone first intercourse 3 to 4 years after menarche. These data suggest that factors such as increased biologic vulnerability may play a role in HPV infections among adolescent women.

Mice immunized with a chlamydial extract have no increase in early protective immunity despite increased inflammation following genital infection by the mouse pneumonitis agent of Chlamydia trachomatis.

We have determined that immunization with a detergent extract of the mouse pneumonitis agent of Chlamydia trachomatis fails to induce a protective inflammatory immune response following genital infection by C. trachomatis. We demonstrated that mice immunized with the detergent extract have increased cutaneous delayed-type hypersensitivity and increased splenic T-cell proliferation in response to the chlamydial extract. After genital infection by C. trachomatis, extract-sensitized mice had significantly increased genital inflammation (P = 0.044) compared with controls. The inflammation was characterized by significantly increased eosinophils in the genitalia (P < 0.0005) and increased genital edema (P < 0.0005). However, the increased genital inflammation of extract-sensitized mice provided no increase in protection against infection (P = 0.92).

Detection of human papillomavirus in cervical swab samples by ViraPap and in cervical biopsy specimens by in situ hybridization.

Human papillomavirus (HPV) detection in cervical swab specimens by ViraPap and in cervical biopsies by the ViraType in situ hybridization assay was correlated with concurrent cytologic and histologic findings in 149 patients. Seven percent of patients with normal samples were positive for HPV DNA, compared with 29% and 69% of patients with low- and high-grade squamous intraepithelial lesions (SILs), respectively. The performance of both assays increased the rate of HPV detection in low-grade lesions but not in high-grade cases. ViraPap was more sensitive than the ViraType in situ hybridization assay in high-grade lesions. The present investigation suggests that HPV DNA detection may be useful in separating confirmed lesions from histologically questionable biopsies.

Detection of human papillomavirus DNA in genital lesions by using a modified commercially available in situ hybridization assay.

A modified, commercially available DNA-DNA in situ hybridization test that uses biotinylated probes for the identification of human papillomavirus (HPV) DNA types 6/11, 16/18, and 31/33/35 was evaluated. HPV DNA was detected in 314 of 787 (40%) histologically abnormal genital biopsy specimens by using the ViraType in situ assay (Life Technologies, Gaithersburg, Md.), in which the hybridization time was increased from 2 to 16 h. Ninety percent of positive condyloma acuminata specimens contained HPV type 6/11 DNA. The prevalences of HPV DNA for cervical intraepithelial neoplasia I, II, and III lesions by this in situ hybridization test were 42, 54, and 55%, respectively. The combined prevalence of HPV type 16/18 and 31/33/35 DNAs increased with the severity of the lesion, while the prevalence of type 6/11 DNA decreased. HPV type 6/11 DNA was found only in 1 of 16 (6%) positive cervical intraepithelial neoplasia III specimens. HPV type 16/18 and 31/33/35 DNA was detected in 11 of 16 (69%) and 4 of 16 (25%) in situ hybridization-positive cervical intraepithelial neoplasia III specimens, respectively. Thus, the observation that certain "higher-risk" HPV genotypes are associated with upper-grade cervical precancer lesions was confirmed by this commercial hybridization system. In general, the assay was found to be well suited for use in the clinical laboratory. The ViraType in situ procedure modified for a longer hybridization time may be helpful in identifying lesions containing higher-risk HPV strains.

Low incidence of positive amnionic fluid cultures in preterm labor at 27-32 weeks in the absence of clinical evidence of chorioamnionitis.

In order to determine the utility of amniocentesis for detecting subclinical chorioamnionitis in asymptomatic afebrile women in preterm labor with intact membranes, we enrolled 47 women between 27-32 weeks' gestation in a prospective study. After enrollment, 38 women fulfilled all clinical and laboratory criteria for the study; nine women were excluded because they had a leukocyte count exceeding 15,000/microL. None of the 38 asymptomatic afebrile women had a positive culture from the amnionic fluid for bacteria, fungi, Mycoplasma hominis, Ureaplasma urealyticum, Chlamydia trachomatis, or any viruses. Sepsis was not proved in any of the 38 infants delivered to these patients. There was a clear relationship between histologic evidence of chorioamnionitis and failure of tocolytic therapy. Fetal lung profiles were mature in 29% of the amnionic fluid samples from 30-32 weeks' gestation, but in none of the amnionic fluid samples before 30 weeks. Amniocentesis does not seem useful to detect chorioamnionitis in asymptomatic afebrile women with preterm labor and intact membranes at 27-32 weeks' gestation, and should be reserved for those cases in which information about fetal lung maturity would be helpful.

Demonstration of human papillomavirus DNA by nucleic acid in situ hybridization in paired histologically abnormal cervical biopsies obtained at the same patient visit.

Fifty-four pairs of cervical biopsies ranging from minimal dysplasia to severe dysplasia were studied for the presence of human papillomavirus DNA by in situ hybridization. Two assays were performed on each biopsy. A 16 hour hybridization was used in one assay, while a 40 hour hybridization was utilized in the second assay. Increasing the hybridization time to 40 hours did not significantly increase the detection rate of HPV compared to the rate found using the 16 hour hybridization. Also, no difference in the detection rate of HPV was found by using one biopsy of the pair over the other biopsy of the pair. However, the performance of a single in situ assay on only one biopsy from each patient significantly underestimated the true prevalence of HPV. A single assay only detected 21/33 (64%) patients with HPV. Implications of multiple testing of all histologically abnormal biopsies is discussed in relation to prospective follow-up studies determining the usefulness of HPV typing in patient management.

In-situ hybridization for the diagnosis and typing of human papillomavirus.

The human papillomavirus (HPV) has been associated with the production of many skin and mucosal lesions, the development of squamous cell carcinoma of the genital areas, skin and aerodigestive tracts, and possibly adenocarcinoma of the uterine cervix. There are more than 60 known genotypes of HPV. Some genotypes have been associated with lesions that have none or minimal chances of malignant transformation; while other genotypes (especially types 16, 18, 31, 35, and 51) have been found in mild, moderate, and severe dysplasia, carcinoma in-situ or frank invasive carcinoma. HPV cannot be propagated in tissue cultures. The presence of the virus can be demonstrated by immunologic techniques, which are not sensitive enough with the present methodology, or by searching for the presence of the viral DNA by DNA or RNA hybridization techniques. Determining the viral genotype in the tissue involved will permit the separation of those lesions supposedly to be low risk from those associated with the high risk types. This knowledge may be helpful in the future to determine the appropriate management of patients infected with HPV.

Detection of human papillomavirus DNA in cervical lesions by in situ hybridization using biotinylated DNA probes.

In situ hybridization (ISH) for human papillomavirus (HPV)-6, -11, -16, -18, and -31 DNA was performed on 615 formalin-fixed paraffin-embedded cervical biopsies using biotinylated DNA probes. Results were obtained from 584 samples with 266 (45.5%) containing HPV-DNA sequences. Ninety percent of condyloma acuminatum specimens were positive for HPV-DNA with 18 of 19 positive cases containing HPV-6 or -11 DNA. The detection rate of HPV in cervical intraepithelial neoplasia (CIN) lesions was 50.6% (239 of 472), while only 8 of 91 (8.9%) cervical biopsies considered to be histologically normal or with minimal dysplasia contained HPV-DNA as demonstrated by ISH. The prevalence of HPV-16, -18, and/or -31 DNA increased with the severity of the lesions, with 20 of 20 (100%) positive CIN-III lesions containing these viral types compared with 102 of 157 (65.0%) positive CIN-I lesions. ISH with biotinylated DNA probes appears helpful in identifying lesions containing higher risk viral strains.

Histologic manifestations of perinatal genital mycoplasmal infection.

Genital mycoplasmas are controversial gynecologic and obstetric pathogens; their role in perinatal morbidity and mortality is ill defined. This retrospective study was conducted to identify autopsy manifestations of perinatal genital mycoplasmal infection. Bacterial and mycoplasmal cultures were obtained from multiple organ sites, along with detailed clinical, autopsy, and histologic information. All materials were screened by two pathologists. Twenty-nine cases were included in the study. In 17 only a genital mycoplasma was isolated, and in 12 cases a genital mycoplasma plus another bacterial pathogen were identified. Significant histologic findings included subpericardial and pleural hemorrhages, polymorphonuclear leukocytes in alveolar spaces, hemorrhage, and tubulocytic changes in the adrenal glands. The placentas revealed villous edema, deciduitis, and funicitis. The changes identified as significant suggest that mycoplasmas either cause hypoxia or promote histologic changes that mimick hypoxia.

Characteristics of recurrent genital herpes simplex infections in pregnant women.

Longitudinal study of 229 pregnancies in 186 pregnant women with recurrent genital herpes simplex virus (HSV) infections revealed an increased incidence of recurrent episodes in the third trimester compared with the first or second trimesters. The duration of symptomatic recurrences did not change with each trimester. Cervical HSV shedding concomitant with HSV culture-positive vulvar lesions did not change significantly with advancing gestation. The presence of an HSV culture-positive vulvar lesion indicated a significantly (P less than .001) greater risk of concomitant cervical HSV shedding (44 of 333, 13.2%) than in pregnant women with HSV culture-positive remote lesions (zero of 60) or in asymptomatic women (27 of 1460, 1.9%). Comparison of the characteristics among 43 pairs of pregnancies in 34 women revealed no consistent change over time. This study of the natural history of genital HSV recurrences in pregnant women demonstrated no proclivity for an increased rate of preterm delivery (1.3%) or congenital anomalies (2.2%) in a predominantly white, non-Hispanic middle-class population.

Isolation of genital mycoplasmas and Chlamydia trachomatis in stillborn and neonatal autopsy material.

Chlamydia trachomatis and the genital mycoplasmas are significantly prevalent in sexually active women. How these organisms may affect the outcome of pregnancy and the neonate was the principal thrust of this investigation. Placenta, liver, and lung tissue were cultured from Mycoplasma hominis, Ureaplasma urealyticum, Chlamydia trachomatis, and aerobic as well as anaerobic bacteria in 432 stillborn and neonatal autopsies. Genital mycoplasmas were isolated from 36 cases (8.3%). Acute chorioamnionitis and funisitis were present significantly more often in cases with genital mycoplasma than in those without these organisms. Isolation of genital mycoplasmas was not associated with an increased incidence of intrauterine fetal death, villitis, hyaline membrane disease, congenital anomalies, or polymorphonuclear leukocytes in alveolar spaces. Chlamydia trachomatis was not found in any of the sites sampled.