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Notizen: Overall, about one-third of women operated upon because of suspected ovarian cancer turn out to have benign disease. This proportion will be even higher when the tumours are small. A more accurate method of determining which are malignant would reduce the number of unnecessary referrals to the cancer centre and increase the scope for conservative management. This pilot study of ultrasound and intravenous microbubble contrast in 20 women with small ovarian tumours enabled the identification of all four malignant lesions with good inter-observer agreement. These preliminary findings suggest that intravenous contrast improves the ultrasound identification of small ovarian malignancies and may provide an accurate way of selecting women who require to be referred urgently for surgery under the auspices of a gynaecological oncologist. The remainder might be considered for laparoscopic surgery or even for observation in some cases.

Notizen: Objective To determine the long term results of treatment of adenocarcinoma in situ by conisation of the cervix using survival analysis.Design A retrospective study in six teaching hospitals in North West Thames.Population Eighty-five women with a histological diagnosis of adenocarcinoma in situ of the cervix in punch or cone biopsy were identified from pathology and clinical databases.Results In one patient a small focus of adenocarcinoma in situ was found in a cervical polyp. Subsequent cytology was normal and no further treatment was undertaken. The 84 remaining women underwent diathermy loop, cold knife cone biopsy, laser cone biopsy, or needle excision of the transformation zone. A hysterectomy or second conisation was performed in 31/84 women (36.9%) as part of the initial treatment. In all, nine (10.6%) had early invasive lesions of which four were squamous. Fifty-nine patients were treated conservatively following one or two conisations (median follow up 78 weeks, range 0–543 weeks). One had a subsequent hysterectomy for menorrhagia. Five women have undergone treatment for suspected recurrence, a 21.5% cumulative rate of further treatment by four years. The cumulative rate of histologically proven recurrence after conservative management was 4.3% at one year and 15% at four years.Conclusions In those cases with clear margins in the cone biopsy, there is a place for conservative management of a selected group of patients who wish to preserve fertility. However, 16.7% of these will require further treatment after four years because of recurrent cytological abnormalities. Women who opt for conservative management should undergo regular, long term surveillance in a colposcopy clinic. Among those women with involved margins in the initial cone biopsy, there is a high incidence of residual disease. A second cone biopsy may be appropriate ‘definitive treatment’ for young women who wish to preserve their fertility if the margins of the second biopsy are clear and there is no evidence of invasion. Even among those for whom a hysterectomy is the proposed ‘definitive treatment’, a second cone biopsy may be required before hysterectomy to avoid inappropriate treatment of an occult invasive lesion.

Notizen: Objectives To document the frequency of pathology in women who complain of postcoital bleeding. To determine whether negative cervical cytology excludes serious pathology in women with postcoital bleeding. To determine whether postcoital bleeding increases the risk of serious pathology in women with an abnormal smear.Design A retrospective study.Setting A university teaching hospital.Population 314 women with postcoital bleeding seen in the gynaecology service from first January 1988 to 31 December 1994.Methods Women were identified from the computerised records of the colposcopy service and copies of correspondence, which was routinely retained on computer. The latter was searched for the text strings coital and intercourse.Main outcome measure Histopathological diagnosis.Results Twelve women (4%) had invasive cancer: 10 were cervical or vaginal cancers and two endometrial cancers. Eight of the 10 cervical or vaginal cancers were clinically apparent. Four women of these 10 had had a normal smear before being referred for further investigation of postcoital bleeding. Two of these cancers were visible only with the aid of the colposcope. Thus, 0.6% of women attending a gynaecology service with postcoital bleeding, a normal looking cervix and a normal smear had invasive cancer of the cervix. Cervical intraepithelial neoplasia were found in 54 women (17.%) and 15 women (5%) had cervical polyps. Nineteen of the 63 women (30%) with significant pathology had a normal or inflammatory cervical smear. No explanation for the postcoital bleeding was found in 155 women (49 %).Conclusions Although invasive cancer is rare in women with postcoital bleeding, it is much commoner than in the general population. It seems likely that cervical intraepithelial neoplasia is also associated with postcoital bleeding, perhaps because the fragile cervical epithelium becomes detached during intercourse. Postcoital bleeding should continue to be regarded as an indication of high risk for invasive cervical cancer and for cervical intraepithelial neoplasia. Prompt referral to a colposcopy clinic is indicated, but most women with postcoital bleeding will have no serious abnormality.

Notizen: The sensitivity and specificity of cervical cytology and of cervicography in the detection of CIN and invasive cancer of the cervix were determined in a screening programme of an asymptomatic population of 418 women. Because all of the subjects were examined colposcopically and biopsies were taken from any suspicious areas, the presence or absence of disease was determined by the histology of directed cervical biopsies independently of the screening methods being tested. Cervicography correctly identified 24 of the 27 women with CIN or invasive cancer, whereas cytology detected only 14 (sensitivity of 0.89 vs. 0.52; P 〈 0.01). Cervicography detected CIN in 11 women with negative smears, six having CIN III. Only one case of CIN I was detected by cytology when cervicography was negative. Two cases of CIN II were not detected by either method. Inclusion in the analysis of the results from 23 women with technically defective cervigrams reduced the size of the difference in sensitivity, but it remained significant (0.74 vs. 0.48; P 〈 0.05). Cervicography was only slightly less specific than cytology (0.92 vs. 0.94; NS). Cervicography appears to be more effective than cytology in screening for cervical premalignancy but may be more demanding of those who perform the test.

Notizen: Immunosuppressed patients have an increased prevalence of cervical intraepithelial neoplasia (CIN) and apparently normal subjects with CIN have evidence of immunosuppression. The immunosuppression may antedate the cervical lesion or be a result of the CIN. One index of an impaired immune response is a reduced ratio of CD4/CD8 peripheral blood lymphocytes. This study sought to confirm that patients with CIN had a reduced CD4/CD8 ratio and to determine whether local treatment of the cervical lesion affected the abnormality. Patients with CIN had a lower mean CD4/CD8 ratio than controls (1.19 vs. 1.83, P 〈 0.01) and more of the patients with CIN had a ratio less than 1.0 [14/38 (37%) vs. 1/30 (3%), P 〈 0.01]. After laser treatment of CIN, the mean CD4/CD8 ratio was higher than before treatment (1.76 vs. 1.19, P 〈 0.01). Paired pre- and post-treatment values in 11 patients confirmed this improvement (mean CD4/CD8: 1.14 vs. 2.08, P 〈 0.01). These findings confirm an association between CIN and a reduced CD4/CD8 ratio. The effect on lymphocytes of treating CIN suggests that the altered ratio is a result of the disease rather than a pre-existing etiologic factor.

Notizen: While there is no doubt that surgical resection of early stage ovarian cancer can be curative, the effect of cytoreductive surgery on the prognosis in advanced disease is less certain. A recent EORTC study does suggest that intervention debulking surgery might improve survival and this requires urgent confirmation. Extensive cytoreductive surgery, removing bowel, parts of the urinary tract or lymph nodes, may have little impact on the survival of women with advanced disease and can result in substantial morbidity. Discretion and experience are required in determining the appropriate radicality of tumor resection to avoid predictable impairment of quality of life.