Predictive value for infection of febrile morbidity after vaginal surgery.

OBJECTIVE: To determine the screening value of febrile morbidity for detecting infections after vaginal surgery. METHODS: A cohort of 431 consecutive women had vaginal surgery at the M. S. Hershey Medical Center from September 1988 through June 1995. Outcomes of febrile morbidity and infection were analyzed. RESULTS: Fifty-four of 431 patients (12.5%) had febrile morbidity. Thirty-five infections (8.1%) were identified, of which only 13 were accompanied by febrile morbidity. Forty-one patients (9.5%) had unexplained fevers. The sensitivity of febrile morbidity for postoperative infection was 40%, specificity was 98%, positive predictive value was 26%, and negative predictive value was 94%. Stepwise logistic regression found blood loss (odds ratio 1.001/mL; confidence interval 1.0001-1.0035), uterine weight (0.987/g; 0.976-0.999), and parity (1.570; 1.146-2.050) as significant independent variables for developing fever. Patient weight (0.984/lb; 0.971-0.998) and type of procedure (2.16; 2.12-6.38) were confirmed as significant independent variables for postsurgical infections. CONCLUSION: Febrile morbidity had limited value as a screening test for postoperative infection, with poor sensitivity and positive predictive value after vaginal surgery.

Arteriovenous malformations of the uterus: an uncommon cause of vaginal bleeding.

Arteriovenous malformations (AVM) are rare entities in gynecology, with only 73 cases reported in the literature. Most commonly they present with vaginal hemorrhage, but other presentations such as congestive heart failure, postmenopausal bleeding, and an asymptomatic mass have been described. These lesions may be congenital or acquired. Acquired lesions are believed to follow trauma or may arise after choriocarcinoma or other gynecologic malignancies. Diagnosis can rapidly be made with color flow Doppler ultrasound or angiography. Additionally, they have been detected using hysteroscopy, hysterosalpingogram, and computerized tomography. Acute management consists of hemodynamic stabilization and possibly placement of a Foley bulb in the uterus or methylergonovine injection. Ultimate treatment depends on the patients desire for fertility. Embolization therapy is variably successful and may allow the preservation of reproductive capacity. To date, five pregnancies after embolization have been reported with varying outcomes. If pregnancy is not desired or embolization fails, hysterectomy remains the treatment of choice.

Staging and recurrence of disease in squamous cell carcinoma of the vulva.

In order to determine the prognostic significance of applying the revised FIGO staging system and identify factors contributing to survival after documentation of recurrent disease, a retrospective chart review of our vulvar cancer population was performed. Over a 17-year interval 135 patients were uniformly treated with primary surgical treatment consisting of radical vulvectomy and bilateral groin dissection. Factors contributing to disease-free survival were analyzed using a Cox proportional hazards model. Covariates of survival after recurrence of disease were analyzed using the log-rank method. Neither the clinical assessment of the groin nodes, nor the presence or absence of perineal involvement were related to outcome. Only lesion size and surgical status of the inguinal nodes were significant predictors of disease-free survival (P = 0.02 and P = 0.03, respectively). In addition, there was a statistically significant relationship between the extent of groin involvement (negative, unilateral positive, and bilateral positive nodes) and associated decrement in disease-free survival (P = 0.01). Thirty patients developed recurrence of disease from 2.0 to 47.3 months following surgery. The location of the recurrence, interval from primary therapy to recurrence, and status of the groin nodes at initial surgery were significant prognostic factors in subsequent survival. The revised staging system demonstrated an improvement in patient stratification compared to the criteria of the prior classification. The data are also consistent with the distinction made between Stage III and IV disease in the new classification. The status of the groin nodes at original surgery remained an important prognostic factor even in those patients who later demonstrated recurrence of disease.

Evaluation of preoperative cardiac risk index values in patients undergoing vaginal surgery.

OBJECTIVE: Our purpose was to evaluate the Goldman and the New York Heart Association cardiac risk index values in a female surgical population and to evaluate age, hypertension, ischemic heart disease, glucose intolerance, cardiac arrhythmia, and estrogen replacement therapy as risk factors for perioperative cardiac morbidity in older women undergoing major vaginal surgery. STUDY DESIGN: A retrospective analysis was performed of perioperative cardiac morbidity in consecutive patients undergoing elective vaginal surgery between August 1987 and October 1993. RESULTS: Four hundred six patients were entered in the study. Eight patients had perioperative cardiac morbidity. The Goldman cardiac risk index and the New York Heart Association functional classification of heart disease were not significant indicators of perioperative cardiac morbidity in this group of patients. In the postmenopausal subgroup of 168 patients hypertension (p = 0.033) and ischemic heart disease (p = 0.004) were statistically significant risk factors for perioperative cardiac morbidity. Glucose intolerance, cardiac arrhythmia, and estrogen replacement therapy were not significant predictors. CONCLUSION: The Goldman cardiac risk index and the New York Heart Association functional classification of heart disease are of questionable utility in a female surgical population undergoing elective vaginal surgical procedures. Hypertension and ischemic heart disease are risk factors for perioperative cardiac morbidity in a postmenopausal subgroup of these patients.

Endometrial squamous cell carcinoma following whole pelvic radiation therapy: response to carboplatin.

A case of Stage IV endometrial squamous cell carcinoma occurring 8 years after a low anterior resection and whole pelvic radiation therapy for a Dukes D colon carcinoma is presented. Koilocytosis was present in the tumor. There was no evidence of human papillomavirus antigen or DNA in the tumor. The patient was treated with surgery followed by six cycles of carboplatin chemotherapy. At the completion of chemotherapy there was no clinical or radiological evidence of disease. The tumor recurred 9 months postchemotherapy and the patient died of disease 17 months postdiagnosis.

CA 125 and CA 19-9 immunolocalization in normal, hyperplastic, and carcinomatous endometrium.

BACKGROUND: Elevated levels of tumor-associated antigens, such as CA 125, have been reported in patients with endometrial carcinomas. This study was done to evaluate the frequency and tissue distribution of CA 125 and CA 19-9 in normal and neoplastic endometrium. METHODS: Consecutive tissue sections were immunohistochemically evaluated using primary antibodies directed against CA 125 and CA 19-9. Antibody-antigen binding was demonstrated using the avidin-biotin technique. RESULTS: CA 125 expression was related to the phase of the menstrual cycle and was most prominent during secretory phase. Positive staining (5% or more of the glandular epithelium) for CA 19-9 was noted in only 4 of 20 patients with normal endometrium. Positive staining for CA 125 (5% or more of the epithelium) was present in 68% of the carcinomas; another 8% of the tumors contained focal staining for CA 125. Positive staining for CA 19-9 was demonstrated in 60% of tumors; another 8% of the tumors showed focal staining for CA 19-9. The markers were concordant in 76% of the tumors evaluated. CONCLUSIONS: Although CA 125 was uniformly expressed by the glandular cells in normal endometrium, CA 19-9 expression appeared to be related to the prevalence of the Lewis A phenotype. Endometrial carcinomas also frequently express these antigens, and the degree of expression was related to the grade and cell type of the tumor.

Correction of massive vaginal prolapse in an older population: a four-year experience at a rural tertiary care center.

OBJECTIVE: To ascertain the success of complex reconstructive vaginal surgery in older women. DESIGN: Retrospective review of hospital and outpatient records. SETTING: Rural tertiary care referral center, Pennsylvania State University Hospital, Hershey, Pennsylvania. PATIENTS: Twenty-four patients referred for massive erosion of the vagina and/or complete procidentia. MEASUREMENTS: Symptoms and anatomic correction of patients' complaints. RESULTS: After surgery, 83 percent were asymptomatic without pelvic relaxation, 4 percent were asymptomatic with pelvic relaxation, 4 percent were symptomatic without pelvic relaxation, and 9 percent were symptomatic with relaxation. CONCLUSIONS: Older women can undergo major vaginal reconstructive surgery with relief of symptoms and restoration of vaginal depth and axis.

Issues in the consumer choice of health care coverage plans.

Developing and implementing successful marketing strategies for prepaid health care coverage plans is becoming an important issue as managers of these plans struggle to remain competitive in the market place. This paper provides insight into the reasons why consumers make choices among varying types of health care coverage plans. Some suggestions are made to plan managers for incorporating these results into the development of marketing strategies for prepaid health care coverage plans.

Significance of atypical cervical cytology in pregnancy.

To ascertain the significance of squamous atypia encountered during routine Papanicolaou smear screening in pregnancy, we reviewed our experience with 76 pregnant women seen during a 4-year period. All were evaluated with repeat cytology and colposcopy during pregnancy and again postpartum. Colposcopic examination during pregnancy revealed a normal transformation zone without evidence of intraepithelial neoplasia in 46 women. In six of these women, repeat cytology was interpreted as cervical intraepithelial neoplasia (CIN) grade 1. In 30 women, an abnormal transformation zone was identified--14 with a negative repeat cytology. In five women, the transformation zone was interpreted as compatible with CIN 2 or CIN 3. Colposcopically directed biopsies were performed in 31 women, in all but two postpartum. Of the 76 women, human papilloma virus or CIN was identified on biopsy in 16 women (21%). We propose that an isolated report of atypical squamous cells on cervical cytology obtained at the initial prenatal visit does not warrant colposcopic evaluation during pregnancy, unless a repeat cytology suggests CIN. Repeat cytology and evaluation to exclude infections and inflammatory lesions is appropriate. However, if a subsequent cytology is abnormal, postpartum colposcopy and colposcopically directed biopsies seem appropriate, since the prevalence of HPV or CIN was 21%.

Peutz-Jeghers syndrome with ovarian sex cord tumor with annular tubules and cervical adenoma malignum.

A patient with Peutz-Jeghers syndrome, a sex cord tumor with annular tubules, and an initially unrecognized adenoma malignum of the cervix is described. The patient presented with a mucinous adenocarcinoma in the vaginal apex. Review of the hysterectomy slides demonstrated an adenoma malignum of the cervix. In addition to a microscopic sex cord tumor with annular tubules of the right ovary, the left ovary contained mucinous cystadenomas. Adenoma malignum remains a difficult diagnosis and is frequently made only after hysterectomy for a presumed benign indication; pathology frequently demonstrates a deeply invasive, unusually well-differentiated adenocarcinoma of the cervix. Patients with Peutz-Jeghers syndrome need careful clinical and cytologic follow-up to exclude such lesions.

Primary mass closure of fascial incisions using a continuous absorbable suture.

Investigations with animal models and reported studies from the obstetric and gynecologic literature as well as the general surgical literature have suggested that a single mass closure is equal or superior to interrupted suture techniques. Over a 12-month period, 150 patients were operated on using a continuous mass technique for fascial closure with No.1 polydioxanone suture (PDS). One hundred thirty-five patients (90%) had risk factors that placed them at increased likelihood for wound complications. No fascial disruptions occurred. Wound complications were noted in 15 patients (10%). This technique merits wider use.

Clomiphene citrate stimulation as an adjunct in locating ovarian tissue in ovarian remnant syndrome.

Ovarian remnant syndrome results from residual ovarian tissue after bilateral oophorectomy. The syndrome is associated with chronic pelvic pain and is suspected when premenopausal levels of FSH and LH are present in a patient with documented bilateral oophorectomy. Histologic demonstration of ovarian tissue at operation confirms the diagnosis. We treated a patient with ovarian remnant syndrome with a 10-day course of clomiphene citrate, 100 mg daily, to stimulate the residual ovarian tissue and facilitate localization. Preoperative ultrasound revealed a 5.0 x 3.5 x 6.2-cm cystic mass in the right adnexal region. Exploratory laparotomy easily localized the mass, and it was removed intact. Histologic slides demonstrated normal ovarian tissue with multiple follicles in various stages of development and a corpus luteum cyst. Clomiphene citrate is capable of stimulating an ovarian remnant, producing an enlarged, cystic structure easily localized by ultrasound. The increased size and preoperative knowledge of the location facilitated surgical removal.

Clinical significance of hyperkeratosis and parakeratosis in otherwise negative Papanicolaou smears.

To ascertain the clinical significance of hyperkeratosis and parakeratosis in otherwise negative Papanicolaou smears, we retrospectively reviewed 96 patients with these findings seen during a 32-month period. Evaluation included repeating the smear and performing colposcopy in all patients. Colposcopically directed biopsy and endocervical curettage were performed when appropriate. Only one patient had human papillomavirus (HPV) infection. The isolated finding of hyperkeratosis or parakeratosis was not associated with an increased incidence of cervical intraepithelial neoplasia or HPV and, clinically, was not associated with uterine descensus or vaginal prolapse.

Implications of sampling the implantation site in the endometrial biopsy for infertility.

Endometrial sampling performed during the cycle of conception occurs uncommonly. Less frequent is inclusion of the implantation site in an endometrial specimen obtained late in the luteal phase during the course of an infertility evaluation. From 1984 to 1987 the implantation site was sampled in 3 of 520 (0.6%) endometrial biopsies for infertility. In each instance the pregnancy did not continue. Two women conceived again within a year; both delivered term infants. The third woman had not conceived after ten months of follow-up. When an infertility biopsy results in a diagnosis of intrauterine pregnancy, further evaluation of the patient should be determined by the clinical situation: even in couples with extremely compromised fertility the woman occasionally will become pregnant. The prognosis for that pregnancy may be poor; however, the prognosis for subsequently conceiving and carrying a pregnancy to term is encouraging. This study demonstrated the relative safety of endometrial sampling in the infertile woman. The use of barrier contraception during the cycle of sampling can further decrease the chance of interrupting an intrauterine pregnancy.

Value of repeat cytology at the time of colposcopy for the evaluation of cervical intraepithelial neoplasia on Papanicolaou smears.

The significance of repeat cervical cytology was evaluated in patients referred for colposcopy because of previous cervical intraepithelial neoplasia (CIN) 1 on cytologic smears. Between Jan 1, 1984, and Dec 31, 1986, 273 such patients were seen. The results of the repeat smears obtained prior to colposcopy were compared with those of colposcopically directed biopsies and of follow-up. The repeat smear was negative in 99 patients; it disclosed squamous atypia in 84, CIN 1 in 64 and CIN 2 or 3 in 26. Thirty-two patients whose repeat smear was negative had biopsy-documented CIN 1-3. Of the 84 patients with squamous atypia, 37 (44%) had biopsy-documented CIN 1-3. Thus, second smears in this group failed to disclose precancerous lesions in at least 69 patients. Of the 90 patients whose repeat smear were interpreted as showing CIN, 64, or 71%, had biopsy-documented CIN 1-3. Patients with a repeat smear showing CIN 1 or greater and normal colposcopy or a negative cervical biopsy must be followed closely: 33% of our study group (6 of 18) were found to have CIN later.

Squamous atypia on cytology. The influence of age.

The optimal management of squamous atypia on cytology has not been determined. Colposcopy has been recommended because of the high false-negative rate of cytology. To evaluate colposcopy, 1,074 consecutive, nonpregnant women presenting with squamous atypia on cytology were examined prospectively with colposcopy and simultaneous repeat cytology. No specific treatment was given prior to evaluation. Biopsy and endocervical curettage were performed when clinically indicated. Two hundred two women (18.8%) had abnormal cervical or vaginal biopsies, 74 had human papillomavirus, and 128 had cervical intraepithelial neoplasia with or without associated papillomavirus infection. Invasive cancer was not detected. Repeat cytology suggested intraepithelial neoplasia in 60 women, 37 (61%) of whom had positive biopsy findings. Such biopsy findings were obtained in 89 of 306 women (29.1%) with repeat squamous atypia on cytology and in 76 of 708 women (10.8%) with repeat negative cytology. When the data were stratified in terms of age, 184/787 (19.6%) abnormal biopsies occurred in women less than or equal to 40 years of age and 18/287 (6.3%) in women greater than or equal to 41. Squamous atypia on cytology should not be ignored. However, women greater than or equal to 41 are at lower risk of having colposcopically detectable abnormalities and can be followed more conservatively.

Significance of a positive Papanicolaou smear in a well screened population.

Of 35,937 gynecologic cytology specimens obtained from the cervix or vagina at our institution during a three-year period, 18 (0.05%) were reported as malignant; ten of these 18 (56%) positive results were due to carcinoma arising from sites other than the cervix or vagina. The site of the primary lesion was the endometrium in four patients, the ovary in three, the colon in one, and the breast in one; in one patient the site of the primary carcinoma was unknown. In our patient population a a positive Papanicolaou smear was more often indicative of a noncervical than a cervical malignancy. In addition to detecting preinvasive and invasive malignancies of the cervix and/or vagina, an annual cytologic smear may hasten the detection of extravaginal primary carcinomas.

The significance of atypical cervical cytology in an older population.

To ascertain the significance of squamous atypia encountered during routine Papanicolaou smear screening in an older population, we reviewed 115 consecutive patients over age 50 seen during a 3-year period. Evaluation included repeating the smear and performing colposcopy in all patients. Colposcopically directed biopsy and endocervical curettage were performed when appropriate. Sixty-seven patients (58.3%) had atrophy, 43 (37.4%) were normal, two (1.7%) had cervical intraepithelial neoplasia grade 1, two (1.7%) had cervical intraepithelial neoplasia grade 2, and one (0.9%) had human papillomavirus (HPV) infection. There was a strong association between squamous atypia and estrogen deficiency. With the correction of the estrogen deficiency, the squamous atypia reverted to normal in a statistically significant percentage of patients. A Papanicolaou smear report of squamous atypia in women over age 50 should not be considered normal; further evaluation is required. The incidence of cervical or vaginal intraepithelial neoplasia and HPV infection is much lower than reported in studies involving younger patients.

Accuracy of Papanicolaou smears. Art or science?

We examined the relationship between various levels of experience and the ability to obtain adequate Papanicolaou smears as defined by the presence of endocervical cells. From July 1, 1984, through June 30, 1986, 16,360 cervical smears were evaluated for the presence of endocervical cells. Of those smears, 9,243 contained endocervical cells; 7,117 did not. The results were evaluated for seven groups of providers: professional staff, residents (postgraduate years 1-4), nurse practitioners and student nurse practitioners. The range of smears with endocervical cells for individual providers was 22.2-73.1%. Significant differences existed between all the groups. Longer training did not equate with greater skill in obtaining endocervical cells. Obtaining adequate smears appears to be as much an art as a science.