Associations between smoking and adenocarcinomas and squamous cell carcinomas of the uterine cervix (United States)

OBJECTIVES

Few studies of smoking and cervical carcinoma have addressed the rare cervical adenocarcinomas or used DNA-based tests to control for human papillomavirus (HPV) infection.

METHODS

This multicenter case-control study included 124 adenocarcinoma cases, 307 community controls (matched on age, race, and residence to adenocarcinoma cases), and 139 squamous carcinoma cases (matched on age, diagnosis date, clinic, and disease stage to adenocarcinoma cases). Participants completed risk-factor interviews and volunteered cervical samples for PCR-based HPV testing. Polychotomous logistic regression generated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for both histologic types.

RESULTS

Eighteen percent of adenocarcinoma cases, 43% of squamous carcinoma cases, and 22% of controls were current smokers. After control for HPV and other questionnaire data, adenocarcinomas were consistently inversely associated with smoking (e.g. current: OR = 0.6, 95% CI 0.3-1.1; > or = 1 pack per day: OR = 0.7, 95% CI 0.4-1.3), while squamous carcinomas were positively associated with smoking (e.g. current: OR = 1.6, 95% CI 0.9-2.9; > or = 1 pack per day: OR = 1.8, 95% CI 1.0-3.3). Results in analyses restricted to HPV-positive controls were similar.

CONCLUSION

Smoking has opposite associations with cervical adenocarcinomas and squamous carcinomas. Although both histologic types are caused by HPV and arise in the cervix, etiologic co-factors for these tumors may differ.

Evaluation of self-collected cervicovaginal cell samples for human papillomavirus testing by polymerase chain reaction

As human papillomavirus (HPV) becomes accepted as the central cause of cervical cancer, longitudinal studies are shifting focus away from causality to a more detailed investigation of the natural history of HPV infections. These studies commonly require repeated samples for HPV testing over several years, usually collected during a pelvic exam, which is inconvenient to the participants and costly to the study. To alleviate the inconvenience and cost of repeated clinic visits, it has been proposed that women collect cervicovaginal cells themselves, hopefully increasing participation in the natural history studies. We evaluated the technical feasibility of self-collection of cervicovaginal cells using a Dacron swab for HPV DNA detection. We compared the self-collected swab sample and two clinician-administered swab samples (one from the endocervix and another from the ectocervix) from a total of 268 women participating in a case-control study of adenocarcinoma and squamous cell carcinomas of the uterine cervix (111 cases and 157 controls). HPV DNA was detected and genotyped using an L1 consensus PCR assay. The overall agreement between the clinician- and self-collected swabs was excellent [88.1%; kappa = 0.73 (95% confidence interval (CI), 0.61-0.85)]. The correlation was highest between the two clinician-administered swabs [kappa = 0.81 (95% CI, 0.69-0.93)] but was still excellent when comparing either clinician-administered swab to the self-administered sample [kappa = 0.75 (95% CI, 0.63-0.87) and 0.67 (95% CI, 0.55-0.79) for ectocervix and endocervix, respectively]. The type-specific agreement between samples was higher for high-risk, or cancer-associated, HPV genotypes than for low risk, noncancer-associated HPV genotypes when comparing the self-administered swab sample to the clinician-administered swab sample (kappa = 0.78 for high-risk versus 0.66 for low-risk HPV infections, t = -1.45, P = 0.15). The decrease in agreement for low risk types was largely attributable to an increased detection of these types in the self-administered sample (McNemar's chi2 = 6.25, P = 0.01 for clinician- versus self-administered swab comparisons). The agreement did not vary significantly by age, menopausal status, case status, or clinic center. We have demonstrated that a self-collected Dacron swab sample of cervicovaginal cells is a technically feasible alternative to clinician-administered cervical cell collection in natural history studies of HPV and cervical cancer.

Use of hormone replacement therapy and adenocarcinomas and squamous cell carcinomas of the uterine cervix

INTRODUCTION

Exogenous hormones may influence the development of cervical adenocarcinomas. Incidence rates of adenocarcinomas and use of noncontraceptive hormones have increased since the 1970s, but few studies have investigated this potential relationship.

METHODS

We conducted a multicenter case-control study of 124 women with adenocarcinomas, 139 women with squamous cell carcinomas matched on age, diagnosis date, clinic, and stage of disease (in situ or invasive) to adenocarcinoma cases, and 307 healthy community controls who were also matched on age, ethnicity, and residence to adenocarcinoma cases. Participants completed in-person interviews regarding exogenous hormone use before diagnosis and other risk factors and volunteered cervical samples for human papillomavirus (HPV) testing via a PCR-based method. Odds ratios (ORs) with 95% confidence intervals (CIs) estimated relative risks.

RESULTS

Only 13 adenocarcinoma cases (10.5%), 7 squamous carcinoma cases (5%), and 20 controls (6.5%) had used noncontraceptive hormones for menopausal symptoms, irregular periods, or disease prevention; most use was short-term, former use. Ever-use was associated with adenocarcinomas (OR = 2.1, 95% CI 0.95-4.6) but not squamous carcinomas (OR = 0.85, 95% CI 0.34-2.1). No trends were seen with duration of use or ages at first use, but unopposed estrogens were positively associated with adenocarcinomas (OR = 2.7). Unopposed estrogens remained associated with adenocarcinomas (OR = 2.0) when analyses were restricted to the HPV-positive controls. Menopausal status was not associated with adenocarcinomas or squamous carcinomas and did not modify the other associations.

CONCLUSION

Although small numbers warrant tentative conclusions, exogenous estrogens, especially unopposed estrogens, were positively associated with adenocarcinomas. Noncontraceptive hormones were negatively but weakly associated with squamous carcinomas.

Oral contraceptives as risk factors for cervical adenocarcinomas and squamous cell carcinomas

To assess the hypothesis that oral contraceptives (OCs) increase the risk of cervical adenocarcinomas, we conducted a six-center case-control study of 124 patients with adenocarcinomas, 139 with squamous cell carcinomas, and 307 population controls. Women between the ages of 18 and 69 who were newly diagnosed with cervical adenocarcinomas between 1992 and 1996 were eligible. Healthy female controls and a second case group of incident cervical squamous cell carcinomas were matched to the adenocarcinoma cases. All participants were interviewed regarding OCs, other risk factors for cervical carcinoma, and utilization of cytological screening, and a PCR-based test determined HPV genotype of cervical samples for both case groups and controls. Use of OCs was positively and significantly associated with adenocarcinomas and positively but weakly associated with squamous cell carcinomas. Associations between OCs and invasive adenocarcinomas (n = 91), squamous cell carcinoma in situ (n = 48), and invasive squamous cell carcinomas (n = 91) disappeared after accounting for HPV infection, sexual history, and cytological screening, but a positive association remained between current use of OCs and cervical adenocarcinoma in situ (n = 33). This association persisted after stratification by screening and sexual history and after restriction according to HPV status, but small numbers made it difficult to exclude detection bias, selection bias, or residual confounding by HPV as potential explanations Current OC use was associated with cervical adenocarcinomas in situ, but we saw no other evidence that OCs independently increase the risk of cervical carcinomas.

Villoglandular adenocarcinoma of the cervix: a report of three cases and review of the literature

Villoglandular adenocarcinoma of the cervix is a distinct histologic type of cervical cancer. Fewer than 60 cases have been reported in the literature. Previous reports suggest that, due to the highly favorable prognosis of this rare histologic type of cervical cancer, conservative surgical therapy with cervical conization or extrafascial hysterectomy alone may be undertaken. In this series, three cases of villoglandular adenocarcinoma of the cervix are described. Preoperatively in each case, the cancer was confined to the cervix and histologic well-differentiated villoglandular adenocarcinoma of the cervix was confirmed. Extended hysterectomy was performed in all cases. In one case, residual invasive endocervical adenocarcinoma was noted. Careful review of the histologic characteristics of these tumors is needed when deciding if these patients can be managed with conservative therapy.

Identification of H, K, and N-ras point mutations in stage IB cervical carcinoma

OBJECTIVE

The ras oncogenes, Harvey (H), Kirsten (K), and neuroblastoma (N), are a family of genes coding for a membrane-associated protein (p21) which possesses inherent guanine triphosphatase (GTPase) activity. Point mutagenesis at codons 12, 13, and 61 has been implicated in ras activation and subsequent cellular transformation. Given the epidemiologic relationship of HPV infection with cervical carcinoma and the tumorigenic interaction of HPV and mutated ras oncogenes, this study was undertaken to identify if mutated ras oncogenes were present in early invasive cervical carcinomas.

METHODS

A combination of polymerase chain reaction (PCR) and dot-blot hybridization was used to determine the frequency and types of ras point mutants occurring in cervical carcinoma. Thirty-three patients with early-stage cervical carcinoma were identified. DNA was extracted from archival tumor samples. ras genes were PCR amplified using flanking primers and hybridized with a series of labeled allele-specific oligonucleotides corresponding to wild-type forms of K12,61, N12,13,61, and H12,61, as well as to all combinations of substitution mutations (7 wild-type, 45 mutants).

RESULTS

ras mutations were identified in 24.2% of specimens. The detected mutations in H, K, and N-ras all occurred at codon 61. This was not the result of PCR or hybridization artifact in that mutations were detected in position 12 and 13 in appropriate control samples.

CONCLUSIONS

Mutant ras has been shown to convert HPV immortalized keratinocytes to the tumorigenic state. Our results indicate that a significant percentage (24.2%) of these early-stage cervical cancers contain activated ras. Additional studies will be needed to evaluate whether codon 61 represents a characteristic "hot-spot" of ras mutation in a subset of cervical carcinoma.

Generation of tumor-specific cytolytic T lymphocytes from peripheral blood of cervical cancer patients by in vitro stimulation with a synthetic human papillomavirus type 16 E7 epitope

OBJECTIVE

Approximately 90% of squamous carcinomas of the cervix harbor the human papillomavirus and type 16 has been detected in nearly 50% of cases. Recent studies in mice have shown that the human papillomavirus type 16 E7 oncoprotein contains peptide epitopes that are processed and presented in association with a major histocompatibility antigen for recognition by cytolytic T lymphocytes. We investigated whether an epitope from human papillomavirus type 16 E7 could be used to generate specific human cytolytic T lymphocytes in patients with cervical carcinoma.

STUDY DESIGN

After radiation therapy, three patients with antigen HLA-A2 and with locally advanced cervical cancer underwent leukapheresis. Epitope-specific cytolytic T lymphocytes were generated from the peripheral blood mononuclear cells by in vitro stimulation with autologous peripheral blood mononuclear cells pulsed with a human papillomavirus type 16 E7, HLA-A2-restricted, synthetic peptide, E7(11-20) (YMLDLQPETT).

RESULTS

In two patients cytolytic T lymphocytes were capable of E7(11-20)-specific, HLA-A2-restricted cytolysis of the peptide-pulsed, HLA-matched, T2 target cell line. Cytolytic T lymphocytes from one of these patients also demonstrated specific cytolysis against the HLA-A2+, HPV-16+ CaSki cervical cancer cell line but did not lyse either HLA-A2+, HPV-16- MS-751 cells or HLA-A2-, HPV-16- HT-3 cells.

CONCLUSIONS

These experiments demonstrate that novel cytolytic T lymphocytes that recognize a human papillomavirus type 16 E7 epitope can be generated by using the peripheral blood mononuclear cells from irradiated patients with cervical cancer. In addition, because CaSki cells were specifically lysed by the cytolytic T lymphocytes, these data indicate that the peptide E7(11-20) is endogenously processed and presented on the cell surface of the CaSki cells. The demonstration of epitope-specific lysis of cytolytic T lymphocytes of HPV-16+ cervical cancer cells supports further efforts to develop human papillomavirus peptide-based vaccines or antigen-specific adoptive immunotherapy for the prevention and treatment of cervical carcinoma.

MR imaging appearance of the uterus in postmenopausal women receiving tamoxifen therapy for breast cancer: histopathologic correlation

PURPOSE

To describe the spin-echo and dynamic gadolinium-enhanced magnetic resonance (MR) imaging appearance of the uterus in women receiving tamoxifen.

MATERIALS AND METHODS

Thirty-five postmenopausal women with breast carcinoma receiving tamoxifen therapy underwent pelvic MR imaging. T1-weighted, T2-weighted, and dynamic gradient-echo T1-weighted sequences were used. Twenty-seven patients underwent uterine sampling within 3 months of MR imaging.

RESULTS

Endometrial width on T2-weighted images ranged from 0.1 to 7.5 cm (mean thickness, 1.1 cm). Two uterine imaging patterns were noted. Patients with pattern 1 findings had homogeneous high signal intensity of the endometrium on T2-weighted images (mean, 0.5 cm) and enhancement of the endometrial-myometrial interface and a signal void in the lumen on gadolinium-enhanced images (18 patients). Patients with pattern 2 findings had heterogeneous endometrial signal intensity on T2-weighted images (mean, 1.8 cm) with enhancement of the endometrial-myometrial interface and latticelike enhancement traversing the endometrial canal on gadolinium-enhanced images (17 patients). Other imaging findings included subendometrial cysts, nabothian cysts, leiomyoma, and adenomyosis. Ten patients with pattern 1 findings had atrophic or proliferative endometria at histopathologic analysis; 12 of the 17 patients with pattern 2 findings had polyps, one of which had a focus of endometrial carcinoma.

CONCLUSION

MR imaging of the uterus showed two distinct patterns in women receiving tamoxifen therapy.

Recurrent granulosa cell tumor of the ovary 37 years after initial diagnosis: a case report and review of the literature

Granulosa cell tumors of the ovary (GCTs) are uncommon neoplasms that are characterized by late recurrence and high survival rates. A case of recurrent GCT presenting 37 years after initial diagnosis is reported with a review of the literature. This case illustrates an example of a very late recurrence and emphasizes the importance of the extended follow-up required for these patients.

Human papillomaviruses: their clinical significance in the management of cervical carcinoma

Studies have shown a strong association between certain human papillomaviruses and the development of cervical carcinoma and its precursor lesions. The oncogenic potential of papillomaviruses has been clearly demonstrated in both laboratory animals and cultured cells. Recent advances in our understanding of viral pathogenesis have provided insights into the natural history of papillomavirus infection and subsequent development of neoplasia. A more thorough understanding of the molecular mechanisms responsible for viral oncogenesis will facilitate the development of novel preventive and therapeutic strategies to prevent and treat papillomavirus-associated cervical neoplasias. Strategies under current investigation are focusing on the induction of effective humoral and cell-mediated immunity, the expression of HPV gene products, and cofactors that interact with HPV gene products to affect cell transformation. As a result of these investigative efforts, prophylactic HPV capsid vaccines and other gene therapies may soon become clinically available.

Ovarian cancer in pregnancy

A pelvic mass in pregnancy is a relatively common entity, especially considering the increased use of ultrasound or early fetal evaluation. These masses can derive from multiple gynecologic and nongynecologic origin, and fortunately the majority will resolve with observation into the second trimester. Masses persisting into the second trimester should be surgically evaluated given the decreased risk to both mother and fetus at this time. For masses persisting into the third trimester, a 2% to 5% risk of malignancy is to be expected. Documentation of disease (FIGO stage) is critically important in defining need for adjuvant cytotoxic chemotherapy. Above all, potentially lifesaving therapy should not be withheld from patients because they are pregnant, especially considering that chemotherapy is apparently safe in the second and third trimesters.

Ineffectiveness of continuous 5-fluorouracil as salvage therapy for ovarian cancer

5-Fluorouracil (5-FU) is an antimetabolite chemotherapy, which selectively functions at the S phase of the cell cycle. It is a short-acting agent with a serum half-life of approximately 11 minutes. Increased efficacy with this drug could theoretically be provided by sustained infusion over the doubling time of a tumor. Ovarian cancer that recurs or persists after treatment with platinum-based chemotherapy has a poor prognosis. This study examines the use of long-term infusional 5-FU as a salvage chemotherapy for ovarian cancer. 14 patients with epithelial ovarian cancer were studied. All were stage III or IV disease and all were initially treated with platinum-based chemotherapy with either persistence or recurrence of disease. Patients received 5-FU as 300 mg/m2/day via a continuous infusion for a 10-week cycle with discontinuation occurring for severe toxicity or documented progression. The average infusion per patient was 8 weeks (3-10). Three patients had drug discontinued secondary to toxicity (severe mucositis) and 4 patients had progression prior to the completion of 10 weeks. All patients had progression by the end of the first cycle. The average survival post-5-FU was 8.9 months (range: 0.75-22 months). The lack of response in 14 patients indicates that, statistically, the likelihood of an overall response rate of 20% is less than 0.05. Infusional 5-FU appears to be ineffective as salvage therapy for ovarian cancer.

Role of conformational epitopes expressed by human papillomavirus major capsid proteins in the serologic detection of infection and prophylactic vaccination

Human papillomaviruses (HPVs) cause a variety of cutaneous warts, mucosal condylomata, and dysplasias and are etiologic in cervical cancer. Papillomavirus (PV) conformational epitopes on the surface of virions are type-specific and are the target of neutralizing antibodies. In this study, we describe two methods of in vitro expression of HPV major capsid (L1) proteins which mimicked conformational epitopes and demonstrate their type specificity and ability to react with neutralizing and/or conformation-dependent antibodies. The L1 open reading frames (ORFs) for HPV-1, 6, 11, and 16 were molecularly cloned into a SV 40 expression vector and the encoded gene products were expressed in mammalian (cos) cells. Similarly, the L1 ORFs for HPV-6, 11, 16, and 18 were molecularly cloned into recombinant baculovirus and the encoded gene products were expressed in insect (SF9) cells. The expressed L1 proteins reacted by immunofluorescence and immunoprecipitation with polyclonal and monoclonal antibodies generated against their corresponding native virions and by Western blotting with antibodies that recognized nonconformational epitopes of denatured virions. The recombinant L1 proteins expressed conformational epitopes in both cos and Sf9 cells that were type-specific and displayed neutralizing epitopes. The ability to express, purify, and qualitate the reactivity of recombinant L1 proteins will now permit the serologic analysis of host response to HPV infection and the development of prophylactic PV subunit vaccines.

Vulvar reconstruction using a mons pubis pedicle flap

The treatment of early vulvar carcinoma has moved toward less radical surgery with reconstruction. This report describes our preliminary experience with a mons pubis flap that is simple and appears safe, reliable, and gives excellent cosmetic and functional results following radical hemivulvectomy. Four patients have undergone this procedure with excellent results. The flap brings pliable, hair-bearing skin which authentically mimics the normal side, thus providing good sexual function. The mons pubis pedicle flap should be considered in patients undergoing radical hemivulvectomy where an excellent cosmetic result is desirable.

Preservation of multiple oncogenic human papillomavirus types in recurrences of early-stage cervical cancers

OBJECTIVES

Our purpose was to determine the relationship between human papillomavirus genotypes contained in primary early stage cervical cancers and those contained in the respective recurrences.

STUDY DESIGN

Six early-stage cervical cancers that were considered cured by surgical extirpation subsequently recurred within 21 months of the original surgery. The primary tumors and the recurrences underwent polymerase chain reaction for human papillomavirus typing with confirmation of types performed by means of diagnostic restriction fragments.

RESULTS

All primary tumors and recurrences contained human papillomavirus, with all primary tumors positive for multiple types. The concordance rate between the primary tumors and recurrences for specific types was 73% (11/15). Among the highly oncogenic types 16 and 18 there was 100% concordance between primary and recurrent tumors.

CONCLUSIONS

Highly oncogenic types of human papillomavirus are preserved between primary tumors and their recurrences in cervical cancers. This further supports the role of oncogenic types in the maintenance of the malignant state and supports the clonogenic nature of cervical cancer recurrence.

The expressed L1 proteins of HPV-1, HPV-6, and HPV-11 display type-specific epitopes with native conformation and reactivity with neutralizing and nonneutralizing antibodies

Previous studies demonstrated that the human papillomavirus (HPV) type 1 L1 protein, expressed in cos cells by an SV40-based vector, displays conformational epitopes characteristic of native virions. In this study, we analyzed the expression of HPV-1, HPV-6, and HPV-11 L1 proteins in order to determine the forms of conformational epitopes expressed by recombinant L1 proteins. Using both immunofluorescence and immunoprecipitation techniques, polyclonal and monoclonal antibodies (MAbs) generated against native HPV-11 virions reacted with expressed L1 proteins of HPV-6 and/or HPV-11, but not HPV-1. Similarly, polyclonal antibodies and MAbs generated against HPV-1 virions reacted with the expressed L1 protein of HPV-1, but not HPV-6 or HPV-11. Of two MAbs that neutralized HPV-11 infection of murine fetal foreskin xenografts, one reacted with the expressed L1 protein of both HPV-6 and HPV-11, and the other reacted with HPV-11 only. A nonneutralizing conformationally dependent MAb reacted with the expressed L1 protein of both HPV-6 and HPV-11. These results demonstrate that expressed HPV L1 proteins retain type-specific, neutralizing, and nonneutralizing conformational epitopes and that cos cells may be utilized to evaluate host immune responses to such epitopes.

Insertion of Groshong central venous catheters utilizing fluoroscopic techniques

Groshong central line indwelling catheters are extensively used in gynecologic oncology patients for administration of chemotherapy, intravenous fluids, and pain medications. They are easy to maintain and have a good safety record. We report on the placement of these central venous catheters under direct fluoroscopic visualization as a method which is safe, inexpensive, and efficacious in high-risk patients. Fluoroscopic visualization during insertion provides several advantages: visualization of bony landmarks, placement of the guidewire into the subclavian vein and superior vena cava under direct visualization, and confirmation of appropriate distal placement of the Groshong catheter. Patient advantages include the following: (1) avoidance of unnecessary punctures to access the subclavian vein; (2) verification of guidewire placement to avoid cephalic placement; (3) passage of the guidewire only as far as the right atrium to avoid potential dysrrhythmias secondary to right ventricular irritation; and (4) a savings of approximately 60% over insertion in the general operating room. Thirty patients had placement under fluoroscopic visualization in the angiography suite of Georgetown University Hospital. The average age of the patients was 58 years (42-78). Sixteen patients had ovarian cancer, 6 had endometrial cancer, 5 had cervical cancer, and 3 had other gynecologic malignancies. Fifteen patients had catheters placed for chemotherapy, 14 for hydration, and 1 for pain control. Ten patients had had previous central venous catheters: 6 had been removed for infection, 2 for thrombus, 1 for completion of chemotherapy, and 1 for catheter kinkage. All 10 with previous catheters had successful placement of catheters in the angiography suite. Complications from insertion were minimal with one asymptomatic pneumothorax and one proximal port in an extravascular position. We present the technique of fluoroscopic insertion of Groshong catheters which is an effective method of placement in high-risk patients.

Colonic surgery in gynecologic oncology. Risk factor analysis

Colonic surgery is a critical part of gynecologic oncology care. A 12-year review of colonic surgery on a gynecologic oncology service was performed evaluating risk factors and their impact on postoperative morbidity. There were 124 procedures performed on 92 patients; 9 patients had no prior surgery, chemotherapy or radiation. Fifty-six percent of the patients were considered malnourished on the basis of a serum albumin level < 3.5 g/dL. The 124 procedures consisted of 57 colon resections with primary reanastomosis, 10 small bowel-colon bypass procedures and 57 colostomies. Of the 57 (67%) colostomy operations, 38 also had concomitant abdominal-pelvic procedures. There were 15 major bowel complications and 17 major systemic postoperative complications. Prior surgery and poor nutritional status significantly correlated with postoperative morbidity; however, prior radiation did not reveal an increased risk for postoperative complications.

Prognostic significance of polymerase chain reaction detected human papillomavirus of tumors and lymph nodes in surgically treated stage IB cervical cancer

This study describes the prognostic role of polymerase chain reaction detected human papillomavirus (HPV) in Stage IB cervical cancer patients treated with radical hysterectomy and pelvic and paraaortic node dissection. All tumors were confined to the cervix and all margins and nodes were disease free. Twenty-one patients were analyzed: 6 patients recurred within 20 months of initial therapy, while 15 had no evidence of disease with a minimum follow-up of 36 months. Polymerase chain reaction (PCR) was performed on paraffin-block tissue of the hysterectomy specimen cervical tumor and lymph nodes. Oligonucleotide probes for HPV types 6, 11, 16, 18, 31, 33, and 35 were used with consensus primers for uncharacterized HPV types created from an L1 constant region. Control tissues were run with each tumor sample to assure against contamination. HPV type confirmation was performed using diagnostic restriction sites. HPV was detected in all cervical tumors. Recurring tumors were infected with multiple types of HPV in all 6 tumors versus only 5 of 15 nonrecurring tumors being multiply infected (P = 0.023). No tumor had HPV 6 or 11, and the incidence of HPV 16, 31, 33, and 35 was not significantly different for recurrent versus nonrecurrent groups. HPV 18 was found in 5 of 6 recurring cancers versus 1 of 15 nonrecurring tumors (P = 0.0029). PCR typing of the histologically negative nodes that had been obtained at radical hysterectomy was done in all 6 recurring patients and in 6 nonrecurring patients. The recurrent patients had a significantly higher incidence of lymph nodes positive for HPV DNA (71%) than the nonrecurring patients (35%) (P = 0.0047). These observations suggest that HPV 18 cervical cancer patients, those with infections of multiple types, and those with HPV DNA in histologically negative lymph nodes may be at increased risk for recurrence.

Radical hysterectomy morbidity in relation to age

The complications of radical hysterectomy in patients 65 years and older were compared with those in women younger than 65. There was no statistical difference in complication rates between the two groups, although the older women had a significantly higher incidence of preoperative medical problems. No surgical deaths occurred in either group. Our data indicate that selected older women can tolerate radical hysterectomy as well as younger ones.

Identification of human papillomavirus type 16 in primary and recurrent cervical cancer following radiation therapy

Formalin-fixed, paraffin-embedded tissue blocks from 13 women with cervical carcinoma that recurred following radiation therapy were evaluated for the presence of human papillomavirus (HPV) by in situ hybridization using ribonucleic acid 35S-labeled probes for HPV types 6, 11, 16, and 18. Ten of thirteen patients also had pretreatment biopsies from their primary tumors available for analysis. HPV 16 was detected in both primary and recurrent lesions in 4 women. In 1 case, HPV was detected in the primary tumor and not in the recurrence. HPV 16 was also present in three recurrent cancers from which primary lesions were not available for probing. Radiation therapy did not alter the hybridization signal strength or pattern, suggesting that the HPV genome copy number was not significantly affected. The persistence of HPV 16 in recurrent cervical carcinoma is consistent with the theory that HPV plays a role in maintaining the malignant state.

Lack of protective effect of thromboxane synthetase inhibitor (CGS-13080) on single dose radiated canine intestine

The effect of a thromboxane A2 synthetase inhibitor (CGS-13080) on canine intestine was studied using a single dose of radiation, and radioactive microspheres were used to determine resultant blood flow. Thromboxane A2 causes vasospasm and platelet aggregation and may play a dominant role in radiation injury. However, there was no effect on the intestinal blood flow diminution occurring after radiation in this laboratory model using this thromboxane A2 synthetase inhibitor.

Human cervical cells immortalized in vitro with oncogenic human papillomavirus DNA differentiate dysplastically in vivo

Human papillomavirus (HPV) types 16 and 18 are associated with cervical dysplasia and carcinoma. In vitro integration of HPV-16 or HPV-18 DNA into cultured human cervical cells results in their immortalization. In this study, in vivo differentiation of human cervical cells immortalized with recombinant HPV-16 or HPV-18 DNA was studied by implanting confluent monolayers of HPV-16 and HPV-18 DNA immortalized cell lines under dorsal skin flaps of immunodeficient mice. Grafts of a human cervical cancer cell line (C4-1) and cultured normal cervical cells served as controls. Histologic analysis 2 to 3 weeks after grafting demonstrated dysplastic differentiation of the HPV-16 and HPV-18 cell lines as characterized by abnormal mitotic figures, nuclear pleomorphism, and loss of basal polarity. RNA in situ hybridization confirmed the presence of viral transcripts in the dysplastic grafts. G-banded chromosome analysis showed that both the HPV-16 and HPV-18 cell lines were aneuploid. Even after prolonged periods of implantation tumors did not form and invasion of underlying mouse stroma did not occur. Normal cervical cells differentiated normally and the C4-1 cell line formed tumors and demonstrated more pronounced nuclear abnormalities than the HPV immortalized grafts. Integration of HPV-16 and HPV-18 DNA into cervical cells leads to an indefinite growth capacity. These aneuploid cells differentiate abnormally in vivo, but do not form tumors or invade host tissue, consistent with a multistage theory of cervical carcinogenesis.

Postoperative adjuvant external-beam radiotherapy in surgical stage I endometrial carcinoma

A combined surgical and radiotherapeutic approach is widely in Stage I endometrial adenocarcinoma. The technique and timing of the radiotherapy varies from center to center. Postoperative external-beam (EB) radiotherapy has the advantage of patient selection based upon surgical findings, comprehensive treatment of the pelvic nodal and vaginal cuff areas, and elimination of the need for an intracavitary procedure. Although frequently utilized, this technique is surprisingly poorly described in the medical literature. From 1979 to 1986, 46 surgical Stage I patients received adjuvant postoperative EB therapy at Georgetown University Hospital (GUH) (Washington, DC). Indications for treatment were Grade greater than or equal to 2 and/or depth of myometrial invasion of greater than 33%. The 5-year actuarial survival was 90% with a disease-free survival of 82%. The failure rate within the irradiated field was 6.5% with a distant failure rate of 8.7%. The rate of significant long-term complications was acceptable at 6.5%. The authors conclude that postoperative EB radiotherapy is an effective adjuvant therapy with results comparable to other available radiotherapeutic techniques.

An alternative approach to the vertical midline abdominal incision for staging in ovarian carcinoma

The case report describes a situation that required staging laparotomy for ovarian cancer but the patient refused vertical incision for cosmetic reasons. The technique employed a low transverse skin incision with development of a skin flap and horizontal transection of the midabdominal wall near the level of the umbilicus. Operative exposure was adequate for standard staging procedures and the cosmetic requirements of the patient were satisfied.

Early management and decision making for the treatment of myelomeningocele

A program for early selection and treatment of the infant with myelomeningocele was developed at the University of Oklahoma Health Sciences Center in 1977. Over a 5-year period, 69 babies were evaluated, 36 babies were recommended for early vigorous treatment. Of the 33 babies for whom only supportive care was recommended, five were initially treated at the parents' request, two underwent delayed vigorous treatment, one was subsequently treated by "crisis management," one moved and did not return for follow-up, and 24 received only supportive care. All 24 babies died between 1 to 189 days of age (mean 37 days). The involvement of several physicians and paramedical support personnel is considered essential for this approach of early selection and treatment. Continued support and regular follow-up is necessary for any baby who receives only supportive care. Parents retain legal custody. Although ethical concerns make any approach difficult, the method presented is considered to be the best alternative available at this time.

A transmissible malignant neoplasm of mice originating in reticular or endothelial cells

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