Bibliothek

Notizen: Summary. Genital papillomatosis accompanied by distressing vulval symptoms is often termed vulvodynia. Common presenting symptoms are vulvar burning, pruritus and dyspareunia. Sixteen patients with vulval papillomatosis (vulvodynia) have been treated by carbon dioxide laser therapy over a 4-year period. Initial responses at 6 weeks appeared encouraging but with follow-up it became apparent that the relapse rate was high, with a mean symptom-free interval of 4–6 months. Of the 16 patients treated, only three remain symptom free. In view of our findings, we recommend that laser therapy should not be offered as a primary procedure, if at all, for patients with vulval papillomatosis.

Notizen: Objective To assess the efficacy of cervical loop excision as primary management of adenocarcinoma in situ.Design A two-centre retrospective study.Setting Birmingham and Midlands Hospital for Women and City Hospital NHS Trust.Population Nineteen women with a histological diagnosis of adenocarcinoma in situ (high grade CIGN) of the cervix made on diathermy loop excision.Main outcome measures Presence or absence of adenocarcinoma in situ at loop specimen margins, results of cervical cytological examinations following loop excision, results of histopathological assessment of any surgical specimens taken after initial loop excision.Results Of the 19 women with confirmed adenocarcinoma in situ on loop excision, the median age was 31, and 8 (42%) were nulliparous. The median follow up of these women was 19 months. Eleven women were treated by loop excision alone and have had normal follow up to 18 months. Five women have undergone further surgical procedures, four had a hysterectomy and one had a repeat loop excision. No residual disease was found in any of these surgical specimens, confirming that loop excision was adequate primary management of the disease. Three women have had abnormal endocervical follow up cytology suggestive of residual disease. One of these three women may represent a case of residual endocervical disease. Excision margins of the loop specimen were not involved by adenocarcinoma in situ in 11 women. However, excision margin status of the loop specimen did not appear to be predictive of residual disease.Conclusions Our small retrospective study suggests that diathermy loop excision of the cervix is adequate primary management of adenocarcinoma in situ of the cervix. Cytological and colposcopic follow up, including cytobrush endocervical cytological sampling and long term follow up, is recommended in these women.

Notizen: Summary. A clinicopathological review of 50 primary malignant melanomas of the vulva in the West Midlands region of England is presented. The overall 5-year-survival rate was 35%, when adjusted for age. Significant predictors of survival were clinical stage, patient age, tumour ulceration, cell type and mitotic rate. Tumour thickness was of prognostic importance but as a prognostic variable it did not operate independently of stage and as most lesions were deeply invasive at presentation vulval tumours must be separated for prognostic purposes into bands at greater overall thicknesses than those used for skin melanomas generally. There was no significant relation between survival and type of surgery performed as a primary therapeutic procedure.

Notizen: Forty-six patients with a primary diagnosis of vulval intraepithelial neoplasia (VIN) have been managed over a 10-year period. The prevalence of VIN has increased and the age at presentation has decreased over the last decade; 59% of our patients had histological evidence of human papillomavirus infection. Pruritis was the commonest symptom at presentation (59%). Of the 46 patients 44 were treated by laser skinning vulvectomy, local excision or simple vulvectomy. Symptomatic relief was best achieved by local excision. Clinical and definitive relapse occurred more often in the laser-treated group. The median time to relapse was 38 months in the laser-treated group and 74 months in the surgically treated group (excision and simple vulvectomy). Two patients have not been treated and their disease has not progressed. The carbon dioxide laser almost certainly has a role in conservative management and although our data possibly do not reflect its full potential they demonstrate a need for a controlled prospective study.

Notizen: Objective To assess the efficacy of cervical conization as primary management of cervical intraepithelial glandular neoplasia (CIGN).Design A multicentre prospective cohort study.Setting CRC Clinical Trials Unit, Birmingham.Subjects 84 women registered with the Unit between May 1986 and January 1989. After excluding 33 women, 51 who had been managed in accordance with the described protocol and had the presence of CIGN confirmed by central review of diagnostic histopathological material were included in the study.Intervention/Protocol Women with CIGN diagnosed on a cervical cone specimen were managed in accordance with a specific protocol: (a) women with negative cone margins were managed conservatively and followed up with regular cervical cytological and colposcopic examinations; (b) women with involved cone margins were managed by hysterectomy.Main outcome measures Presence or absence of CIGN at cone margins, results of cervical cytological examinations following conization, results of histopathological assessment of any surgical specimens taken after initial cone biopsy.Results Of the 51 women with confirmed CIGN, managed by conization, 14 (27%) were aged 30 or less and 15 (29%) were nulliparous. Thirty five women who had a cone biopsy showing margins free of CIGN have been managed by conization alone. After a median follow-up period of 12 months there is no apparent residual CIGN or invasive disease in this group. Thirteen women have had further surgical procedures (according to protocol) and two have had a hysterectomy for benign gynaecological disorders. Eight further procedures were carried out because the original cone biopsy had margins involved with CIGN, and only one of them was found to have residual CIGN. The other five procedures were carried out solely because of abnormal cytology, only one of them had a diagnosis of CIN 1. A total of 10 women had cytological abnormality following cone biopsy, one had CIGN, one had CIN 1 and a third had CIN 3.Conclusions Our preliminary data suggests that when a diagnosis of CIGN is made upon a cone biopsy, further surgery is unnecessary in those women in whom the margins of the cone specimen are free of disease. Cytological and colposcopic follow up, including cytological sampling of the endocervical canal, is recommended for these women.

Notizen: Summary. The staining reactions of the monoclonal antibodies anti-EMA, AGF 4:48 and the lectin UEA-1 from Ulex europaeus were investigated in formalin-fixed, paraffin-embedded sections of 36 primary ovarian carcinomas. The staining patterns were graded and related to tumour type, differentiation, FIGO stage and patient survival. Both antibodies and UEA-1 showed variations in their staining between and within tumours. The staining of mucinous tumours using anti-EMA was significantly less than in non-mucinous tumours. No other significant associations were found between staining grade and the different variables under study. The variations in staining were not demonstrated to have any prognostic significance.

Notizen: Objective To compare immediate and deferred treatment in women with cervical smears showing borderline nuclear abnormalities or mild dyskaryosis.Design Prospective randomised trial.Setting Colposcopy clinics at Birmingham and Midland Hospital for Women and the City Hospital NHS Trust, Dudley Road, Birmingham.Participants Four hundred and thirty-five women with minor cytological abnormality younger than 35 years of age, of whom 353 were randomised to immediate treatment or deferred treatment.Main outcome measures Comparison of histologies in the subsequent two years in the immediate and deferred treatment groups.Results Thirty-six women (21%) defaulted from follow up. The percentage of high grade abnormalities (CIN II and III) in the deferred treatment arm at two years is similar to that in the immediate treated arm at first colposcopy (25%vs24%). Cytology failed to pick up two cases of CIN III and there was one case of early invasive carcinoma at the six month follow up. If treatment is deferred, the proportion with CIN I is almost halved (25%vs13%); the proportion with koilocytic atypia is slightly reduced (51%vs42%) and the proportion with no abnormality is substantially increased (0.6% vs 20%).Conclusion Immediate referral and a select-and-treat management strategy of all women with any degree of dyskaryosis is recommended based on the case of invasive cervical cancer, high default rate and the failure of cytology to pick up two cases of CIN III.

Notizen: Objective To investigate the long term outcome of patients with vulvar intraepithelial neoplasia.Design A retrospective study using information obtained from patient casenotes.Sample One hundred and thirty-three women with a primary diagnosis of vulvar intraepithelial neoplasia (VIN), identified during a 15-year period.Results The diagnosis of vulvar intraepithelial neoplasia increased throughout the study period. Human papilloma virus changes were noted in 104 patients (78%); these women were significantly younger than those without (P≤ 0.001). Nineteen (14%) were managed by observation or medical treatment and the remainder by surgical methods. Histological or symptomatic recurrence after surgical treatment occurred in 55 (48%). When disease recurred, it usually did so within four years of treatment. Recurrence was more common following laser vapourisation than after local excision (75%vs 40%; P≤ 001). Progression to invasive disease occurred in nine patients (7%), none of whom were in the group being observed. Four deaths occurred in this group, three from gynaecological malignancies of the lower genital tract.Conclusions Patients with vulvar intraepithelial neoplasia require long term follow up, and the risk of invasion may be higher than previously thought. Surgical treatment when required should be by excisional rather than ablative methods in most instances. In selected cases it is also possible to safely manage patients by more conservative methods.