The most common chromosome aberration detected by high-resolution comparative genomic hybridization in vulvar intraepithelial neoplasia is not seen in vulvar squamous cell carcinoma

We analyzed genetic changes in condylomas (four cases), vulvar intraepithelial neoplasia I-III (VIN I-III, eleven cases), and primary vulvar squamous cell carcinomas (VSCC, ten cases) by high-resolution comparative genomic hybridization (HR-CGH) and flowcytometry. All samples were also human papilloma virus (HPV)-genotyped. Gain of chromosome 1, the aberration most often seen in VIN III (67%), was not seen in HPV-positive or -negative VSCCs (0%). Both VIN III and VSCC frequently showed gain of 3q (56 and 70%, respectively). The VIN III samples often demonstrated gain of 20q (56%) and 20p (44%), and the VSCC samples gain of 8q (60%), loss of 3p (50%), and 8p (40%). None of the four most frequent changes in the VSCC samples occurred exclusively in the HPV-positive or -negative samples. As expected, we did not find any cytogenetic changes in condylomas and nearly any changes in VIN I-II.

Evaluation of screening procedures for congenital cataracts

AIM

To evaluate the efficacy of two different Swedish screening procedures for early detection of congenital cataracts in comparison with no screening.

METHODS

Children born between January 1992 and December 1998 in Swedish regions with an established eye-screening routine procedure, diagnosed with congenital cataract, and operated on before 1 y of age, were included in a retrospective study. Age at referral and age at time of the operation were compared between regions using different screening procedures: screening in the maternity wards (Region 1), at the well-baby clinics (Region 2) and one region without any screening (Region 3).

RESULTS

Seventy-two children were included in the study. Concerning early diagnosis and surgery, Region 1 differed significantly from Regions 2 and 3, which were more similar and were combined for further analysis. The difference in detected cases was greatest at 21 d of age (55% vs 18%; p < 0.001), but persisted even at 100 d of age (78% vs 64%; p < 0.02). Region 1 screening resulted in more and earlier cases detected than the other two regions (22 vs 15 per 100,000 births). In 72% of all cases, surgery was performed in response to referrals from either the maternity wards (36%), or the well-baby clinics (36%). However, half of the cases from the well-baby clinics were detected too late, i.e. at > 100 d.

CONCLUSION

Eye screening in the maternity ward is preferable to well-baby clinic screening and to no screening at all, since it leads to early detection. Screening should also be performed routinely at well-baby clinics within the period when successful treatment is possible.

Effect of epidural bupivacaine vs combined epidural bupivacaine and morphine on gastrointestinal function and pain after major gynaecological surgery

In a double-blind study, we investigated the effects of postoperative epidural local anaesthetic, with or without addition of epidural morphine, on postoperative pain and gastrointestinal function in patients scheduled for radical hysterectomy and pelvic lymphadenectomy. Forty patients were randomized into two study groups: 48-h postoperative epidural 0.2% bupivacaine 8 ml h(-1) (bupi group) or 48-h postoperative epidural 0.2% bupivacaine/morphine 50 microg at 4 ml h(-1) (bupi/morph group). Patients were observed for at least 96 h after surgery. No differences in pain at rest, during cough or mobilization were observed. Patients in the bupi group requested a significant greater amount of supplementary analgesics, but times to first flatus and defaecation were reduced compared with patients in the bupi/morph group. Itching was a significant problem in patients in the bupi/morph group. No differences in postoperative nausea and vomiting, mobilization or time to discharge from hospital were observed between groups. The addition of morphine to postoperative epidural bupivacaine has only limited effect on pain relief and increases time to normalization of gastrointestinal function.

Effect of peri- and postoperative epidural anaesthesia on pain and gastrointestinal function after abdominal hysterectomy

In a double blind study we have investigated the effects of epidural local anaesthesia (LA), when added to general anaesthesia (GA) and postoperative paracetamol and NSAID, on postoperative pain and gastrointestinal function in patients undergoing open hysterectomy. Sixty patients were randomized into three study groups: GA, and postoperative paracetamol and NSAID (GA, n=20); GA, paracetamol, NSAID, intraoperative epidural lidocaine and 24-h postoperative epidural saline (Saline, n=20); or GA, paracetamol, NSAID, intraoperative epidural lidocaine and 24-h postoperative epidural bupivacaine (Bupi, n=20). Patients were observed for 72 h postoperatively. Pain at rest, during cough, and mobilization, request for supplementary morphine, and time to first postoperative flatus, was reduced in patients receiving 24-h postoperative epidural anaesthesia, compared with the two other groups. However, these effects of epidural LA, were not sustained beyond the period of infusion, and no differences in PONV, time to first postoperative defecation, mobilization or time to discharge from hospital were observed between groups. A 24 h postoperative epidural infusion with bupivacaine, when added to postoperative paracetamol and NSAID, reduces pain and opioid requirements, but has only limited effects on gastrointestinal function and patient recovery.

Osteoclast-like giant cells in leiomyomatous tumors of the uterus. A case report and review of the literature

Osteoclast-like giant cells (OLGC) in leiomyomatous tumors of the uterus are rarely seen, and their significance is unknown. We present a case of a large leiomyomatous tumor in which OLGC were found in only few sections showing leiomyosarcoma whereas the majority of sections revealed a leiomyoma. Though radically operated, the patient died a few months later with recurrent tumor in the pelvis and metastases to the lungs.

Staging uterine cervical carcinoma with low-field MR imaging

PURPOSE

To assess the validity of low-field MR in staging cervical cancer compared to clinical staging.

MATERIAL AND METHODS

A total of 95 women entered the study over a 3-year period. MR examinations with a 0.1 T resistive magnet using a body coil and clinical staging according to the FIGO recommendations (1988) were performed within 2 weeks from clinical diagnosis. T1- and T2-weighted sequences were obtained in transversal and sagittal acquisitions, and an additional T1 before and after contrast (randomisation to 0.1 or 0.3 mmol/kg b.w. gadodiamide). Treatment decisions on surgery or radiation therapy were made solely on the clinical staging.

RESULTS

Sixty-one patients were found to be eligible for surgery. In 5 women, the pathological results revealed a more advanced stage of the disease than assessed by clinical staging. MR correctly staged 4 of the 5 but otherwise tended to overstate the disease. Contrast enhancement significantly reduced this trend (p<0.05) regardless of the contrast medium dose used. Divided into two groups, an operable (less than stage 2b) and an inoperable group (more than stage 2a), the clinical staging correctly classified 57 patients (accuracy 92%) compared to 52 patients with MR using contrast enhancement (accuracy 84%). The specificity was no higher than 31%, whereas the reproducibility of the MR assessment was fairly good with kappa values around 0.65 for both intra- and inter-observer variations.

CONCLUSION

In the present set-up, clinical assessment was superior to low-field MR in staging cervical cancer. When using contrast enhancement, the staging accuracies of low-field MR were comparable to the ones reported for techniques with higher tesla values, whereas the specificity and reproducibility errors were lower. The method, therefore, needs to be optimised.

Cervical intraepithelial neoplasia in pregnancy

OBJECTIVE

To determine the progression/regression rate of cervical intraepithelial neoplasia in pregnancy and to describe the number of patients requiring treatment for cervical neoplasia during or following the pregnancy.

METHODS

A retrospective analysis of 305 pregnant women with abnormal cervical cytology was performed. The colposcopic, cytologic and histologic findings of repeated examinations during pregnancy and of the subsequent examination eight weeks postpartum were registered and compared. All smears were obtained by cotton bud and Cytobrush. Colposcopy was performed using standard techniques and cervical biopsies were taken in case of colposcopic abnormalities. Endocervical curettage was omitted during pregnancy. At postpartum evaluation colposcopy, directed biopsies and endocervical curettage were performed in all cases.

RESULTS

One hundred and two patients (33%) were followed only by cytology and colposcopy. The remaining 203 patients (67%) had one to four colposcopically directed biopsies during the pregnancy. Comparing the initial histology in pregnancy to the postpartum histologic evaluation 25% showed spontaneous regression while 75% of the women exhibited progression (28%) or persistence (47%) in the severity of cervical neoplasia. Two patients were treated by cervical conization in early pregnancy and 143 women (53%) were treated within the first year after the pregnancy. In the postpartum period microinvasive carcinoma was diagnosed in two patients, but no women advanced to more serious stages of cervical cancer.

CONCLUSIONS

The high persistence rate of cervical intraepithelial neoplasia in pregnancy leads us to recommend a liberal use of colposcopically directed biopsies during pregnancy and to ensure a high follow-up rate in the postpartum period.

Pilot study of nebulized surfactant therapy for neonatal respiratory distress syndrome

Thirty-four spontaneously breathing newborns with respiratory distress syndrome (RDS) requiring nasal continuous positive airway pressure (CPAP) and an arterial-to-alveolar oxygen tension ratio (a/A PO2) of 0.15-0.22 were randomized to treatment with nebulized surfactant (Curosurf) or to serve as controls. All children were first supported by nasal CPAP according to normal clinical routines. Surfactant was administered using a modified Aiolos nebulizer, and a total of 480 mg was aerosolized in each case. The control group received no nebulized material, but had the same CPAP support. Acid-base status and a/A PO2 were determined at regular intervals before, during and after surfactant administration. Both groups included in the study were similar with regard to gestational age, birthweight, steroids given before birth, sex and Apgar scores as well as a/A PO2 when entering the study. There were no significant differences between the groups in a/A PO2 1-12 h after randomization, number of infants needing mechanical ventilation, time on ventilator or CPAP. Two children in the treated group developed bronchopulmonary dysplasia. No side effects of the surfactant therapy were noted. No beneficial effects of aerosolized surfactant were demonstrated in our trial, contrary to data from animal experiments. This finding probably reflects differences in administration techniques. Our findings do not justify large clinical trials with the same protocol. Further work is needed to optimize delivery of aerosolized surfactant to the neonatal lung in clinical practice.

[Atypical endometrial hyperplasia. Prognosis and course]

The treatment of patients with the diagnosis atypical endometrial hyperplasia has been disputed during the last decades. The aim of the study was to evaluate the treatment of these patients and analyse the progression rate to invasive carcinoma of the endometrium. Fifty-seven patients with atypical hyperplasia were examined and treated from 1976 through 1991. The medical records were examined retrospectively and the pathology slides were revised by one pathologist in accordance with the 1975 WHO recommendations. Thirty-one (54%) patients were on oestrogen treatment as monotherapy at the time of diagnosis. Forty-two patients had a hysterectomy performed within five months, and five patients had a hysterectomy performed 10 to 61 months after diagnosis. A total of 18 out of 57 patients (31.6%) had or developed endometrial carcinoma all with myometrial invasion: 14 stage I with < or = 50% myometrial invasion, three stage I with > 50% myometrial invasion, and one stage IV. There was no significant difference in age, body mass index, parity or hormone replacement treatment between the group with endometrial carcinoma and the group without endometrial carcinoma. We conclude that unopposed oestrogen treatment and nulliparity are the main risk factors for atypical hyperplasia and that hysterectomy is the appropriate treatment for patients with atypical hyperplasia of the endometrium.

[Estrogen replacement in women treated for breast cancer]

Oestrogen replacement therapy in women with a history of breast cancer has long been considered contraindicated. However, the literature does not indicate an increased risk of recurrent breast cancer in postmenopausal women receiving oestrogen replacement therapy. We advocate that women with a history of breast cancer without nodal involvement could be offered oestrogen replacement therapy and thereby benefit from prevention of cardiovascular disease and osteoporosis. But the patients must accept a potentially increased risk of recurrence. We emphasize the need for randomized prospective studies.

Empiric monotherapy for febrile neutropenia--a randomized study comparing meropenem with ceftazidime

In this Swedish multicentre study we compared the efficacy of meropenem with ceftazidime for treatment of febrile neutropenia. 192 patients were randomized and the number of evaluable patients was 92 in the meropenem group and 95 in the ceftazidime group. 40 (43%) patients in the meropenem arm and 49 (52%) in the ceftazidime arm had acute leukaemia. 56 (61%) and 52 (55%) patients respectively had a neutrophil count of < 0.1 x 10(9)/l at randomization and the median duration of neutropenia was 6.5 and 8 d, respectively. Thirty-one (34%) and 28 (29%) patients had a microbiologically defined infection, 14 (15%) and 17 (18%) a clinically defined infection and the remaining 47 (51%) and 50 (53%) had unexplained fever. After 72 h of treatment, 46 (50%) patients in the meropenem arm and 53 (56%) patients in the ceftazidime arm were alive on unmodified monotherapy. 42 (46%) and 47 (49%) of these completed the study on monotherapy alone. Only 2 patients (2%) in each arm had to stop treatment owing to allergic reactions. None of the observed differences were statistically significant and we therefore conclude that meropenem was an effective and safe alternative to ceftazidime for empiric treatment of fever during neutropenia.

[Estrogen replacement to women treated for endometrial cancer]

Oestrogen replacement therapy in women treated for endometrial cancer has long been considered contra-indicated. Based on a review of the literature, which shows a low risk of recurrence during oestrogen replacement therapy in women treated for low-risk endometrial cancer, we advocate that this group of patients could be offered oestrogen replacement therapy and be provided with the benefits of prevention of cardiovascular disease and osteoporosis. Further studies are needed to investigate the survival and recurrence rates of high-risk patients treated with oestrogen replacement therapy.

Interactions of spermidine and methylspermidine with DNA studied by nuclear magnetic resonance self-diffusion measurements

The NMR pulsed field gradient self-diffusion method has been used to study the self-diffusion of the polyamine spermidine and the polyamine analog methylspermidine (completely N-methylated spermidine). The self-diffusion coefficient, D, was measured in solutions of calf thymus DNA prepared from nucleosome core particles (with an average length of 120 base pairs) as a function of the concentration ratio of polyamine to DNA phosphate. A study of the self-diffusion quotient, D/Do (where Do is the diffusion coefficient for free polyamine, not associated with DNA), in additions of spermidine and methyl-spermidine to solutions of NaDNA/NaCl, gave almost identical results with complete association of polyamine to DNA in the initial part of the titrations, indicating similar affinities for DNA. A large influence on the measured self-diffusion coefficients was detected for methylspermidine in NaDNA solutions with different concentrations of NaCl, which shows a considerable salt effect on the polyamine-DNA association. No notable differences in D/Do for methylspermidine were observed in competitive titrations of solutions of Li- and NaDNA, indicating that sodium and lithium ions behave similarly in their interactions with DNA. In titration experiments of methylspermidine into MgDNA solution, the results showed that the polyamine association is less effective than in the case of NaDNA, because of competition from magnesium binding to DNA. Comparisons with calculations based on the electrostatic Poisson-Boltzmann cell model were performed. It is suggested that the interaction is primarily of electrostatic nature, with no binding to specific sites on the DNA molecule.

An NMR self-diffusion study of the interactions between spermidine and oligonucleotides

Self-diffusion coefficients have been determined by pulsed field gradient nmr methods for spermidine in solutions of the oligonucleotides d(GC)4 and d(GGAATTCC). The self-diffusion behavior of spermidine in solution of d(GC)4 is very similar to that observed previously for methylspermidine (completely N-methylated spermidine). Moreover, the self-diffusion behaviors of spermidine in solutions of d(GC)4 and d(GGAATTCC) are also quite similar, indicating that there is no significant influenceon on self-diffusion of oligonucleotide base composition. Furthermore, self-diffusion coefficients of the oligonucleotide d(GC)8 show only a small dependence on oligonucleotide concentration, and no measurable dependence on sodium ion or magnesium ion concentration.

Human papillomavirus in vulvar squamous-cell carcinoma and in normal vulvar tissues: a search for a possible impact of HPV on vulvar cancer prognosis

Paraffin-embedded sections of vulvar squamous-cell carcinomas and of normal vulvar tissues were examined for HPV types 6, 11, 16, 18 and 33 by the polymerase chain reaction. Overall, 19 of 62 tumours harboured HPV DNA of types 16, 18 or 33. HPV types 6 and 11 were not detected. HPV DNA was found in 61% of tumours with adjacent intraepithelial neoplasia (VIN III), and in 13% of tumours without associated VIN III. HPV DNA was not detected in any of 101 normal vulvar tissues. HPV DNA was found more often in younger women, in patients with VIN III-associated tumours, and in those with multicentric anogenital neoplasia. This points to the existence of a subset of vulvar carcinomas preceded by intraepithelial neoplasia, with HPV as a major factor in carcinogenesis. HPV also seems to be an important factor in the development of multiprimaries in these patients. The 2 groups of patients with vulvar carcinoma did not differ with regard to prognosis, as estimated by the risk of recurrence after primary surgery.

The significance of histology and morphometry in predicting lymph node metastases in patients with squamous cell carcinoma of the vulva

The material consists of a series of 73 patients with squamous cell carcinoma of the vulva. The site and the size of the primary tumor and the histological status of the lymph nodes of the groin were known. Two pathologists evaluated nuclear hyperchromatism, nuclear polymorphism, histological differentiation, number of mitoses, inflammatory response, and vascular invasion and graded these parameters from one to three. The reliability of the histopathological grades evaluated by the kappa coefficient showed considerable interobserver variation. Despite this a model which included the subjective parameter nuclear hyperchromatism could predict patients without lymph node metastases. The model consisted of patients with tumors which were not situated on the clitoris, were less than 40 mm in diameter, and exhibited only slight hyperchromatism. The model fitted 19 (26%) and 14 (19%) of the patients with two different pathologists evaluating the nuclear hyperchromatism and none of these patients had lymph node metastases. The quantitative parameter--mean nuclear volume--determined by morphometry was of no diagnostic value for the prediction of patients without groin node metastases at the time of operation.

Localized interaction of the polyamine methylspermidine with double-helical DNA as monitored by 1H NMR self-diffusion measurements

The 1H NMR pulsed field gradient self-diffusion method has been used to measure the diffusion coefficient of the polyamine analogue methylspermidine (completely N-methylated spermidine) in DNA solution, as a function of the concentration ratio of methylspermidine to DNA phosphate. Three different DNA's have been investigated: d(GC)4 (8 base pairs), core length calf thymus DNA (approximately 120 base pairs), and sonicated high molecular weight calf thymus DNA (average 7500 base pairs). For a constant ratio of methylspermidine to DNA phosphate, the diffusion coefficient decreases with increasing DNA length. Moreover, at low concentration ratios the diffusion coefficient of methylspermidine approaches a limiting value that is close to that of the DNA molecule. The experimental data are well reproduced by a two-state diffusion model. In this model the diffusion coefficient of the polyamine is a population-weighted average of polyamine associated with DNA (with a diffusion coefficient given by that of the DNA molecule) and polyamine free in solution.

Induction of labor by vaginal prostaglandin E2. A randomized study comparing pessaries with vaginal tablets

A prospective randomized study of 267 pregnant women was undertaken to compare the efficacy of a pharmacy-prepared 3-mg prostaglandin E2 (PGE2) vaginal suppository with a 3-mg PGE2 vaginal tablet for induction of labor and cervical ripening. No statistically significant difference in success frequency was found between the two groups, either on the first day (72% and 74%, respectively; p greater than 0.05) or on the second day (89% in both groups). There was an equal proportion of women requiring oxytocin augmentation in the two groups, but the slower releasing properties of the vaginal tablet were reflected in a longer mean induction--delivery interval of about 4 h for this group. In both the pessary and the vaginal tablet groups, women who had not gone into labor on the first day showed a statistically significant increment in the Bishop score on the morning of the second day. The frequency of cesarean section was the same in both groups, but instrumental deliveries were more frequent in the vaginal tablet group. It is concluded that PGE2 vaginal tablets--a chemically stable alternative to pharmacy prepared pessaries--appear to be effective as regards cervical ripening as well as for labor induction.

Sexual function and somatopsychic reactions after local excision of vulvar intra-epithelial neoplasia

Eighteen patients, under the age of 60 years, who have been treated with local excision of the vulva, participated in the study in which sexual function and somatopsychic reactions were evaluated by personal interviews. Furthermore both objective and subjective cosmetic results were registered. After this type of operation, fewer than one-third of the patients had postoperative sexual and somatopsychic problems, whereas more than half of the patients undergoing vulvectomy did report such problems. Fourteen out of 18 patients were satisfied with the cosmetic result and in 12 of the patients no disfiguration was found. This study shows that local excision of intra-epithelial neoplasia of the vulva is far less sexually traumatic than is vulvectomy.

[Difficulties in early differential diagnosis of intra/extrauterine pregnancy]

Employing the new very sensitive pregnancy tests, pregnancy can be confirmed several weeks before it can be visualized by ultrasonic scanning or can be seen at laparoscopy or laparotomy. This involves the risk that unnecessary diagnostic interventions are performed in early pregnancy with symptoms suggestive of extrauterine pregnancy. Three case reports are quoted to illustrate the problems involved.

[Treatment of cervix cancer in Denmark]

The current status of cervical cancer treatment in Denmark is discussed. Diagnostic aspects and problems of classification are presented briefly supplemented with a comment on new prognostic parameters based on a semiquantitative score system and flow cytometry. Surgery is the treatment of election for the early stages whereas radiotherapy is the treatment of choice in advanced stages. Chemotherapy should only be employed in the framework of clinical trials. It is concluded that centralised treatment should be maintained.

Laser and cryo surgery for cervical intraepithelial neoplasia. A randomized trial with longterm follow-up

In a randomized study, 204 patients with exocervical intra-epithelial neoplasia were allocated to either laser evaporation (103) or cryocoagulation (101). The patients were treated on an outpatient basis without anesthesia. In the case of initial treatment failure the same method was to be used for retreatment. One hundred and eighty-seven patients were followed-up for an average of 50 months (12-80). Eighty-six of 94 laser-evaporated patients (91%) and 89 of 93 cryocoagulated patients (96%) were cured after one treatment. Five of 8 laser failures and 3 of 4 cryo failures were cured by retreatment. The cure rate after one or two laser evaporations was 97% (91 of 94 patients), and after one or two cryo coagulations, 99% (92 of 93 patients). Eighty per cent of residual or recurrent neoplasia occurred within 15 months and 96% within 2 years of treatment. No invasive neoplasia occurred during the follow-up period and no tendency was seen towards higher grades of intra-epithelial neoplasia in the failures compared with the initial diagnoses. It is concluded that laser evaporation and cryocoagulation are equally effective for the treatment of exocervical intra-epithelial neoplasia.

Value of four models for selecting patients for local excision of invasive squamous cell carcinoma of the vulva

For 75 women with squamous cell carcinoma of the vulva who underwent radical vulvectomy and inguinofemoral lymphadenectomy, the authors assessed the efficacy of four models for selecting patients who could have been treated adequately with local excision of the tumor. Each of the three models proposed by Andreasson and Nyboe covered 25% of the patients, none of whom had groin metastases or died of cancer. Local recurrence in the vulva occurred in 10%. A model suggested by the International Society for the Study of Vulvar Disease covered almost 10% of the patients. One of seven patients had groin metastases, none died of cancer, and one of seven developed local recurrence in the vulva. The criteria of the clinically best suited model are tumor not situated on the clitoris and less than 4 cm in diameter, with only slight hyperchromasia. This model ought to be tested in a randomized study.

Outpatient treatment of cervical intra-epithelial neoplasia. The CO2 laser versus cryotherapy, a randomized trial

In a randomized study, 204 patients were allocated to either laser or cryo treatment for cervical intra-epithelial neoplasia (CIN). The patients were treated on an outpatient basis without anesthesia unless other conditions requiring anesthesia had to be dealt with at the same time. Both the laser and the cryo method were highly acceptable to the patients. Slightly more patients experienced moderate or severe pain during laser treatment, compared with cryo treatment (P = 0.05). Peroperative hemorrhage did not exceed 25 cc except for one laser-treated patient. Postoperative vaginal discharge was more often seen after cryo coagulation, the discharge being malodorous in 36% of cryo-treated patients and in 17% of laser-treated patients. Pelvic inflammatory disease was found in one patient in each treatment group. Postoperative spotting occurred more often in laser-treated patients (49%) than in cryo-treated patients (22%). At follow-up colposcopy 3 months after treatment, the squamocolumnar junction was fully visible significantly more often in laser-treated patients (P less than 0.001). The cure rates after one laser or cryo treatment were 90% and 91%, respectively. Subsequent to 19 initial treatment failures, 8 patients have at present been retreated with the same method as initially used, and all 8 are cured. The cure rates after one or two treatments are 96% in the laser group and 93% in the cryo group. The rates are preliminary, due to the short observation time. Publications will appear when all patients have been followed for 2 and 5 years.

Sexual function and somatopsychic reactions in vulvectomy-operated women and their partners

Sexual function and somatopsychic reactions were examined in 25 women following vulvectomy and in 15 of their partners. More than half of the women had both sexual dysfunction and psychological problems. Their partners had no sexual dysfunction but almost half had psychological problems. An important reason for this seems to be insufficient information and advice both pre- and postoperatively and failure to recognize a developing stricture of the introitus vaginae. Frequent control and advice to both partners both pre- and postoperatively is desirable. Less extensive surgical procedures in selected cases should be considered.

Value of prognostic parameters in squamous cell carcinoma of the vulva

In a series of 137 patients with cancer of the vulva who had undergone radical surgery we investigated, by means of a Cox regression model, which combination of clinical variables and clinical as well as histopathological variables afforded the best prediction of survival/death from cancer and survival/death from other causes. Among clinical variables the best prediction was afforded by a combination of tumor site in the clitoris/not clitoris, tumor size greater or smaller than 40 mm, obesity/not obesity, and age. Among clinical and histopathological variables the best prediction was by a combination of groin node metastases/not groin node metastases, tumor site in the clitoris/not clitoris, degree of differentiation high/moderate + low, and age. The combination of clinical and histopathological variables had a significantly better predictive power than clinical variables alone. The best prognostic group in both combinations had a 5-year-survival for cancer of 98%, while the poorest prognostic group in the two combinations showed a 5-year survival for cancer of 19 and 9%. The best predictors of death from causes other than cancer were age and a poor general health. It is concluded that the poorest prognostic group is definitely under treated and that the best prognostic group is presumably over treated. Patients in poor general health and with a good cancer prognosis should receive a more conservative treatment.

Intraepithelial neoplasia in the vulvar region

From 1978 to 1982, 49 patients with intraepithelial neoplasia in the vulvar region were included in a prospective investigation. The main purpose was to evaluate the effect of treatment by local excision with a free margin of 2 mm and to estimate the importance of colposcopy. In 28% of the patients, the disease recurred after primary treatment, and in one patient microinvasion was shown. No patients died of cancer. A risk factor of recurrence was involvement of resection margins. Multicentric localization of the vulvar disease was found more frequently among patients treated for intraepithelial neoplasia of the cervix. In 66% of the patients the colposcopic findings were consistent with intraepithelial neoplasia. Local excision represents an improvement in the treatment of intraepithelial neoplasia of the vulva, but frequent follow-up is necessary.

Predictive factors with reference to low-risk of metastases in squamous cell carcinoma in the vulvar region

Among 122 patients operated upon for squamous cell carcinoma in the vulvar region 14 variables were investigated by a logistic regression analysis to determine their predictive value as to the presence/absence of metastases to the inguinal nodes. Factors of predictive value proved to be hyperchromasia, polymorphism, involvement of the clitoris, depth of invasion, and tumor size. On the basis of these variables, three different models of low-risk groups were set up. Model I comprised patients whose tumors showed slight hyperchromasia and did not involve the clitoris [metastatic rate: observed 0, estimated 2.1% (0.4-9.8%)]. Model II comprised patients whose tumors showed slight hyperchromasia, did not involve the clitoris, and measured less than 4 cm [metastatic rate: observed 0, estimated 1.6% (0.3-7.8%)]. Model III comprised patients whose tumors showed slight hyperchromasia, did not involve the clitoris, and had an invasion depth of less than or equal to 5 mm [metastatic rate: observed 0, estimated 1.3% (0.2-7.1%)].

Dermatofibrosarcoma protuberans of the vulva

A woman aged 52 years had a tumor of the mons pubis. The morphologic picture, featuring a whirling of spindle cells with long slender, interdigitating cell processes and so-called labyrinth nuclei, conformed to a dermatofibrosarcoma protuberans. Wide local excision is sufficient therapy, but more experience with this rare sarcoma of the vulva is necessary.

Induction of labor. A double-blind randomized controlled study of prostaglandin E2 vaginal suppositories compared with intranasal oxytocin and with sequential treatment

In a double-blind randomized controlled study of 300 women, 150 primiparas and 150 multiparas, induction of labor by means of vaginal suppositories containing 3 mg prostaglandin E2 (PGE2) was compared with the conventional method of intranasal oxytocin and with a combined method of 3 mg PGE2 vaginal suppositories alternating with intranasal oxytocin. In the PGE2 group the intensity of delivery was significantly greater than in the oxytocin group, among both primiparas and multiparas and among the patients with ripe and unripe cervix. The efficiency of the combined treatment could no be evaluated because of the high intensity of delivery during the first 24 hours. There were no maternal side effects, and no significant difference in the frequencies of failed induction and cesarean section.

Diuresis and urine concentration during CPAP in newborn infants

The impact of continuous positive airways pressure (CPAP) on diuresis and urine concentration was studied in newborn preterm infants with respiratory insufficiency with and without pulmonary X-ray changes. Urine output and osmolality, sodium balance and blood pressure were measured before, during and after CPAP application. In all infants urine osmolality rose and urine output decreased significantly when high CPAP (8 cm H2O) was applied, especially in infants without radiographic pulmonary changes. Three infants also developed hyponatremia at high CPAP levels. The results indicate that high CPAP levels per se may affect fluid balance inadvertently. Therefore fluid intake and urine output should be monitored closely during CPAP treatment.

Pregnancy in Crohn's disease

Over a 13-year period, the course of 109 pregnancies in 68 women with Crohn's disease was studied. A total of 76 children were delivered. There were no gemellary deliveries, and none of the children had congenital malformations. Pregnancy entailed no increased risk of an exacerbation of the bowel disease. As compared with the reference population and with women with ulcerative colitis, the total material showed an increased risk of premature delivery and spontaneous abortion, but a further analysis showed that this was due only to an increased risk in women with active disease at the time of conception and in women who had undergone bowel resection during pregnancy. Birth weight and birth length corresponded to those in the reference population. The frequency of neonatal hyperbilirubinaemia was not higher in children of mothers with Crohn's disease than in children of healthy mothers. Treatment with sulphasalazine, salazosulphadimidine, and corticosteroids did not influence the course of pregnancy or the frequency of neonatal jaundice or malformations. Consequently, in Crohn's disease a pregnant woman should be given the same medical treatment as when not pregnant. Generally, the women should be advised preferably to conceive at a time when their bowel disease is inactive. The risk groups should be followed up with frequent obstetrical examinations throughout pregnancy.

Pregnancy in ulcerative colitis

The course of pregnancy in 97 women with ulcerative colitis was studied over a 12-year period. During this period they had 173 pregnancies and delivered 136 children. There were two gemellary deliveries. Nine women had a spontaneous and 16 an induced abortion, of which 4 were performed on therapeutic indication. For a woman with ulcerative colitis the risk of an exacerbation of the bowel disease was 32% per year in her fertile years, whereas it was 34% per year during pregnancy. This difference is not statistically significant. As compared with women with an inactive bowel disease, women in whom the disease was active at the start of pregnancy had a small but significantly greater risk of spontaneous abortion and premature delivery. The frequency of malformations, prematurity, and neonatal hyperbilirubinaemia was not higher in the children of ulcerative colitis mothers than in those of healthy mothers. Treatment with sulphasalazine, salazosulphadimidine, and corticosteroids had no influence on the course and outcome of pregnancy. Birth length and weight of the children of mothers with ulcerative colitis equalled those for children of healthy mothers. In conclusion, pregnancy does not necessitate any change in the usual medical treatment of ulcerative colitis. Women with ulcerative colitis should be advised preferably to conceive at a time when their bowel disease is inactive. Generally, ulcerative colitis constitutes no indication for induced abortion.

Verrucous carcinoma of the vulval region

Verrucous carcinoma is a variant of epidermoid carcinoma with distinctive clinical and pathological features. The diagnosis is often difficult. To date, 20 verrucous carcinomas involving the vulva have been reported in the literature. Metastases to the inguino-femoral lymph nodes have not been described. The treatment of choice is wide local excision. Clinical features, histological findings, and therapy are discussed.

Invasive cancer in the vulvar region

During the past 25 years there has been a tenfold increase in the incidence of vulvar cancer in Denmark. For this reason a material of 195 patients treated during the period 1960-77 is reviewed. There had been a considerable delay in treatment, due partly to the patients and partly to the doctor first seen. The five-year survival rate was 63.3%, corrected 84.2%. The prognosis is highly influenced by the size of the tumor, its appearance, the presence of unilateral or bilateral metastasization to the inguinal nodes, the histological type, and localization of the tumor. On the basis of these features, it is possible to single out groups having a particularly poor prognosis in whom the surgical treatment is insufficient and ought to be supplemented. Clinical assessment of the inguinal lymph nodes carries a considerable uncertainty, yet the FIGO staging is based mainly upon this assessment. This goes some way towards explaining why no prognostic differences were found between stages I, II, and III. Postoperative staging based upon the histological diagnosis would provide greater prognostic certainty.