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Objective: To estimate the prevalence of anal intraepithelial neoplasia in heterosexual women with genital intraepithelial neoplasia, and to compare anal cytology with colposcopy for their effectiveness in anal intraepithelial neoplasia screening.Methods: Women with confirmed intraepithelial neoplasia on the cervix, vagina, or vulva were referred for gynecologic oncology care. All patients underwent anal cytology and high-resolution anoscopy. Any lesion detected on anoscopy was biopsied. Wilson score method was used to estimate 95% confidence interval for prevalence. McNemar's test compared the two screening methods.Results: Women with average age of 39.6 years (range 14 to 83 years) underwent anal cytology and anoscopy (N=205). Of the 205 patients with genital intraepithelial neoplasia, 25 patients (12.2%) had biopsy-proven anal intraepithelial neoplasia. Twelve patients (5.9%) had abnormal anal cytology (nine with atypical squamous cells of undetermined significance [ASC-US], three with low-grade squamous intraepithelial lesions [LSIL]). None of the nine patients with anal ASC-US had biopsy-proven anal intraepithelial neoplasia. Of the three patients with anal LSIL, two had anal intraepithelial neoplasia II and one had condyloma on biopsy. However, 78 patients (38%) had abnormal anoscopy findings that resulted in 25 biopsy-proven anal intraepithelial neoplasias (8 anal intraepithelial neoplasia I, 5 anal intraepithelial neoplasia II, 12 anal intraepithelial neoplasia III)), condylomas (n=11), and hyperkeratosis (n=8). Anoscopy identified 32% (25 patients) with anal intraepithelial neoplasia out of 78 abnormal anoscopic examinations. In diagnosing anal intraepithelial neoplasia, anoscopy has 100% sensitivity and 71% specificity; anal cytology has 8% sensitivity and 94% specificity.Conclusion: Patients with cervical, vulvar, and vaginal intraepithelial neoplasia have 12.2% prevalence of anal intraepithelial neoplasia and should be screened with high-resolution anoscopy. In anal intraepithelial neoplasia screening, anoscopy is more sensitive but less specific than anal cytology. [ABSTRACT FROM AUTHOR]

This selection from the NCCN Guidelines for Ovarian Cancer focuses on the less common ovarian histopathologies (LCOHs), because new algorithms were added for LCOHs and current algorithms were revised for the 2016 update. The new LCOHs algorithms include clear cell carcinomas, mucinous carcinomas, and grade 1 (low-grade) serous carcinomas/endometrioid epithelial carcinomas. The LCOHs also include carcinosarcomas (malignant mixed Müllerian tumors of the ovary), borderline epithelial tumors (also known as low malignant potential tumors), malignant sex cord-stromal tumors, and malignant germ cell tumors., (Copyright © 2016 by the National Comprehensive Cancer Network.)

Objective: The aim of this study was to assess the incidence of and risk factors for hypomagnesemia in patients undergoing gynecologic surgery by a gynecologic oncologist., Methods: A retrospective chart review was performed on all patients undergoing surgery for gynecologic pathology from July 2011 to July 2015 by a single surgeon. Demographic data, surgical indication, surgery performed, preoperative laboratory values, postoperative laboratory values, and medical history were examined. Hypomagnesemia was defined as less than 1.8 mg/dL. Hypermagnesemia was defined as greater than 2.5 mg/dL., Results: Six hundred sixty-nine patients were identified for analysis. One hundred ninety-seven patients had hypomagnesemia (29.4%). Four hundred sixty-six patients had normal magnesium levels (69.5%), and 6 patients had hypermagnesemia (1%). Among patients with benign disease, 24.9% had preoperative hypomagnesemia compared with 32.7% of patients with a gynecologic malignancy. African American race (P = 0.041), diabetes mellitus (P < 0.001), and malignancy (P = 0.029) were all associated with preoperative hypomagnesemia. Diabetes and major surgery were associated with postoperative hypomagnesemia (P = 0.012 and P = 0.048, respectively). Hypomagnesemia was associated with increased preoperative and postoperative pain (P = 0.049 and P < 0.001, respectively) as well as postoperative hypokalemia (P = 0.001). Age, body mass index, hypertension, cancer type, hematocrit, surgical indication, and length of hospital stay were not associated with hypomagnesemia., Conclusions: Perioperative hypomagnesemia is prevalent in patients undergoing gynecologic surgery by a gynecologic oncology, especially in patients who have a gynecologic malignancy. We recommend routine preoperative and postoperative evaluation of serum magnesium in all patients undergoing gynecologic surgery by a gynecologic oncologist.

Objective: To evaluate the acetowhite changes of the vulva as a predictor for high grade vulvar intraepithelial neoplasia., Methods: We performed retrospective analysis from 344 patients referred to our gynecology oncology clinic for genital dysplasia. All patients underwent vulvar colposcopy. Vulvar biopsies were performed for acetowhite changes and visible vulvar lesions such as ulceration, hyperpigmentation, and thickening of the vulvar tissue. High grade vulvar dysplasia was defined as vulvar intraepithelial neoplasia 2 or worse. Results of the vulvar pathology were collected and sensitivity, specificity, negative and positive predictive values., Results: Of the 344 women who underwent vulvoscopy 241 patients had acetowhite lesions, of whom 89 had true high grade dysplasia. Using colposcopic acetowhite changes as a marker for high grade vulvar dysplasia, the test's sensitivity was 97 %, specificity was 40 %, negative predictive value was 98 %, and the positive predictive value was 37 %., Conclusion: Acetowhitening of the vulva has high sensitivity but low specificity as a predictor of high grade vulvar intraepithelial neoplasia. The absence of acetowhite lesion can reassure that high grade vulvar lesion is absent.

Objective: To study the association of a multimodal pain protocol (MMPC) and reduced hospital stay after open abdominal hysterectomy., Study Design: The study design was a comparison of a prospective cohort with a retrospective historical control. We enrolled endometrial cancer patients undergoing open abdominal hysterectomy with lymphadenectomy by the same surgeon. Control patients from 2008 to 2010 who received morphine PCA alone were compared with a similar demographic group of patients from 2011 to 2013 who received MMPC. MMPC consisted of gabapentin (900mg PO) and acetaminophen (1g IV) administered 45-60min preoperatively. The surgical site was injected with bupivacaine with 0.5% epinephrine prior to incision. The postoperative pain control regimen consisted of gabapentin (300mg PO every 6h), acetaminophen (1g IV every 8h for 24h postoperatively), ketorolac (15mg IV every 6h for 48h postoperatively), morphine PCA (2mg IV every 10min, no basal rate) and oxycodone/acetaminophen (10/325mg PO every 6h as needed)., Results: Length of hospital stay (LOH) of the study cohort (N=105 with MMPC) was compared with the historical with postoperative morphine alone (N=113 without MMPC). There were no differences in demographic, uterine cancer stage, or comorbidities between the two arms. The LOH was 1.6 days for patients receiving MMPC and 3.3 days for patients who received morphine alone (P<0.001)., Conclusion: Multimodal pain control is associated with significantly reduced hospital stay after open abdominal hysterectomy., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: The purpose of this study was to investigate the relationship between imaging and the multivariate index assay (MIA) in the prediction of the likelihood of ovarian malignancy before surgery., Study Design: Subjects were recruited in 2 related prospective, multiinstitutional trials that involved 44 sites across the United States. Women had ovarian imaging, biomarker analysis, and surgery for an adnexal mass. Ovarian tumors were classified as high risk for solid or papillary morphologic condition on imaging study. Biomarker and imaging results were correlated with surgical findings., Results: Of the 1110 women who were enrolled with an adnexal mass on imaging, 1024 cases were evaluable. There were 255 malignant and 769 benign tumors. High-risk findings were present in 46% of 1232 imaging tests and 61% of 1024 MIA tests. The risk of malignancy increased with rising MIA scores; similarly, the likelihood of malignancy was higher for high-risk, compared with low-risk, imaging. Sensitivity and specificity for the prediction of malignancy were 98% (95% CI, 92-99) and 31% (95% CI, 27-34) for ultrasound or MIA; 68% (95% CI, 58-77) and 75% (95% CI, 72-78) for ultrasound and MIA, respectively. For computed tomography scan or MIA, sensitivity was 97% (95% CI, 92-99) and specificity was 22% (95% CI, 16-28); the sensitivity and specificity for computed tomography scan and MIA were 71% (95% CI, 62-79) and 70% (95% CI, 63-76). Only 1.6% of ovarian tumors were malignant when both tests indicated low risk. A logistic regression model to predict risk of malignancy is presented., Conclusion: An understanding of how pelvic imaging influences the MIA score can help clinicians better interpret the malignant risk of an ovarian tumor., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objective: We wish to develop a CT scan-based scoring system which estimates the probability of adnexal mass malignancy., Methods: Patients (324) undergoing adnexal mass surgery were recruited into the study from June 1, 2002, to January 1, 2009. All study patients had a preoperative CT scan and serum CA-125 test. CT scan abnormalities included any solid tumor components, ascites, and pelvic or abdominal lymphadenopathy and omental caking., Results: There were 225 (70%) benign and 99 (30%) malignant ovarian masses. Using logistic regression with the area under the curve of the receiver operating curve of 82%, the cancer probability was determined by the equation. e(-3.6372+0.0306*(A)+0.001*(C)+1.551*(D)+1.7377*(E)+2.76*(F)) / 1+e(-3.6372+0.0306*(A)+0.001*(B)+0.876*(C)+1.551*(D)+1.7377*(E)+2.76*(F)) where A = age, B = CA-125, C = solid adnexal mass is 1 and cystic is 0, D = ascites is 1, E = omental caking is 1 and absence is 0, F = node size ≥1 cm is 1 and <1 cm is 0 value. The natural logarithm e is a constant [2.718281828]. For example, for a woman of age 60, CA-125 = 50 U/mL, with solid adnexal mass, ascites, omental caking, and lymphadenopathy, the probability is 0.994. Hence, this woman has a 99.4% probability of having cancer., Conclusion: The computed tomography adnexal mass score combines CT scan findings, CA-125, and patient age into an equation to predict the malignant probability of an adnexal mass.

These NCCN Guidelines Insights focus on the major updates to the 2013 NCCN Guidelines for Ovarian Cancer. Four updates were selected based on recent important updates in the guidelines and on debate among panel members about recent clinical trials. The topics include 1) intraperitoneal chemotherapy, 2) CA-125 monitoring for ovarian cancer recurrence, 3) surveillance recommendations for less common ovarian histopathologies, and 4) recent changes in therapy for recurrent epithelial ovarian cancer. These NCCN Guidelines Insights also discuss why some recommendations were not made.

Objective: To identify risk factors associated with anal intraepithelial neoplasia and develop a model for predicting the likelihood of anal intraepithelial neoplasia in heterosexual women., Methods: A prospective cohort of 327 patients from 2006 to 2011 with a biopsy-confirmed diagnosis of genital intraepithelial neoplasia (vulvar, vaginal, or cervical) underwent both anal cytology and anoscopy. Variables significant between those with and without anal intraepithelial neoplasia were identified using logistic regression. A forward stepwise regression analysis was carried out to identify a combination of variables that effectively predicted anal intraepithelial neoplasia., Results: In the cohort of analyzed patients, 64 (46.7%) women with anal intraepithelial neoplasia were identified, yielding a prevalence of 19.6%. Immunosuppression, vulvar dysplasia, multiple sexual partners (more than four), smoking history, and history of anal sex were positively associated with anal intraepithelial neoplasia (P<.05). These variables were analyzed using forward stepwise logistic regression. The final model used the presence of any two of three risk factors (vulvar intraepithelial neoplasia [VIN], immunosuppression, and history of anal sex) to predict 38.8% of anal intraepithelial neoplasia in our population. Area under the receiver operating characteristic curve for two of three of the factors was 0.708 (P<.05). This model has a negative predictive value of 88.2% (95% confidence interval [CI] 0.83-0.92) and positive predictive value of 43.1% (95% CI 0.31-0.56)., Conclusion: A simple predictive model based on the presence or absence of two of three risk factors (VIN, immunosuppression, and history of anal sex) can be used by the clinician to quantify anal intraepithelial neoplasia risk in women with genital dysplasia., Level of Evidence: II.

Objective: We wished to investigate the prevalence of missing lymph nodes (MLN), factors contributing to MLN, and the effect of MLN on progression free survival (PFS)., Methods: Patients with uterine cancer undergoing abdominal hysterectomy and lymphadenectomy were recruited. All surgeries adhered to the Gynecologic Oncology Group protocol in collecting all the lymph node tissues in paraaortic, common iliac, obturator fossa, and external and internal iliac bilaterally. Data regarding race, age, body mass index (BMI), lymph node counts, staging, location of missing lymph nodes, length of surgery, and estimated blood loss were collected and analyzed in reference to missing lymph nodes. The definition of missing lymph node was an incomplete nodal specimen obtained without actual lymph node tissue., Results: Between April 2003 and January 2010, 235 consecutive patients were enrolled prospectively; 108 patients had missing lymph nodes post-operatively (46%), and 127 patients had complete lymph nodes. We found no correlation between MLN relative to race (P = 0.97), age (P = 0.25), BMI (P = 0.09), estimated blood loss (P = 0.38), American Society of Anaesthesiologist physical status classification system (P = 0.18), surgery time (P = 0.22), hospital stay (P = 0.05), nodes without cancer (P =0.12), nodes with cancer (P = 0.99), stage (P = 0.90), grade (P = 0.17), or PFS (P = 0.29)., Conclusion: In our study, although prevalence of missing lymph nodes seems relatively high, none of the perioperative variables studied appeared to contribute to missing lymph nodes. Finally, missing lymph nodes did not affect progression free survival., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: Persistent human papillomavirus (HPV) infections can cause intraepithelial neoplasia of the lower genital tract. Immune-compromised women have higher rates for all lower genital tract intraepithelial neoplasia. We wish to study the distribution of genital intraepithelial neoplasia in women with and without an immune system., Methods: The study consisted of 343 women with an abnormal genital lesion or cervical cytology who were referred to a gynecologic oncologist. All patients underwent vulva, vaginal, cervical and anal colposcopy. Any lesion detected was biopsied. Demographic and medical data were collected. The Chi-square test was used to determine the relationship between immunosuppression status and various variables, including sites of intraepithelial neoplasia., Results: Immune-compromised women (N = 33) are more likely than immune-competent women (N = 310) to have intraepithelial neoplasia of the vulva (p < 0.05) and vagina (p < 0.05), but not more likely to have intraepithelial neoplasia of the anus or cervix. Immune-compromised women are more likely than immune-competent women to have multifocal intraepithelial neoplasia (p < 0.001). In addition, immune-compromised women are more likely to have higher grade disease of the vulva and vagina (p < 0.05), and no more likely to have higher grade disease on the cervix or anus than immune-competent women., Conclusion: Women with conditions suppressing the immune system are at higher risk for HPV-related disease outside of the cervix and for worse HPV-related diseases than immune-competent women. This study highlights the need for vigilant evaluation of the complete lower genital tract in women with immune-compromised systems.

Unlabelled: Effective postoperative pain management provides improved patient comfort and satisfaction, earlier mobilization, fewer pulmonary and cardiac complications, reduced risk of deep vein thrombosis, faster recovery, and reduced cost of care. Although many therapeutic modalities are available for pain management, the optimal combination in managing postoperative pain in total abdominal hysterectomy is controversial. The objective of this study was to review the literature to formulate optimal, evidence-based preoperative, intraoperative, and postoperative pain management for women undergoing total abdominal hysterectomy. Using the OVID platform, we searched in MEDLINE and PubMed using MeSH terms postoperative pain and total abdominal hysterectomy for published articles from 1960 to the present; we found 545 studies. We screened and included only randomized clinical trials, publications in English, human studies, and abdominal hysterectomy for noncancerous indications. We excluded 456 studies that reported on animal studies; laparoscopic, vaginal, supracervical, or robotic hysterectomy; pharmacokinetic studies; primary outcome other than pain management; and chronic pain management. Studies with inadequate power, poor methodology, or inconclusive results were further excluded from this review. Thus, 89 studies constituted the cohort for our article. Pain control remains complex given variables such as age, anxiety, and extent of surgery. In general, regimens should be tailored to the needs of the individual patient, taking into account medical, psychological, and physical condition. A multimodality approach is better than conventional, single-agent narcotic in achieving optimal pain management. After reading this article, the reader should be able to understand various modalities that can be considered for preoperative, intraoperative, and postoperative pain management in total abdominal hysterectomy., Target Audience: Obstetricians and gynecologists, family physicians Learning Objectives: After completing this CME activity, physicians should be better able to understand various modalities that can be considered for preoperative, intraoperative, and postoperative pain management in total abdominal hysterectomy.

These NCCN Guidelines Insights focus on the major updates for the 2012 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Ovarian Cancer by describing how and why the new recommendations were made. The 6 update topics were selected based on recent important updates in the guidelines and on debate among panel members about recent clinical trials, and include: 1) screening, 2) diagnostic tests for assessing pelvic masses, 3) primary treatment using neoadjuvant chemotherapy, 4) primary adjuvant treatment using bevacizumab in combination with chemotherapy, 5) therapy for recurrent disease, and 6) management of drug/hypersensitivity reactions. These NCCN Guidelines Insights also discuss why some recommendations were not made (eg, panel members did not feel the new data warranted changing the guideline). See "Updates" in the NCCN Guidelines for Ovarian Cancer for a complete list of all the recent revisions.

► The youngest case of endometrial carcinoma in the English literature ► Endometrial cancer is diagnosed in approximately 13-19% of women with Cowden Syndrome. ► Screening guidelines should follow that of Lynch Syndrome.

Objective: Cigarette smoking is a risk factor for cervical, vaginal, vulvar, and anal dysplasia. We will study the prevalence of cigarette smoking in patients with genital dysplasia and effect of counseling on smoking cessation., Methods: All patients with genital dysplasia were screened for smoking history. One clinician provided smoking cessation counseling using the US Department of Health 5 A's technique: ask patients about their smoking status, advise smokers to quit, assess their readiness to quit, assist with their smoking cessation effort, and arrange for follow-up visits. Patients were informed on how smoking may cause worsening of genital dysplasia and increased risk of progression to cancer. Each patient received 2 counseling sessions, but no pharmacological or psychological interventions. Smoking cessation was evaluated by patient self-report via phone or during clinic visits., Results: From January 2007 to December 2010, 344 patients were referred to our gynecologic oncology clinic for evaluation of genital dysplasia. Patients who were smokers (n=125, 36%) were counseled to cease smoking in 2 counseling sessions, with 100% compliance for attendance. At study analysis (July 2011), 83 patients still smoke and 40 patients quit smoking (smoking cessation rate of 32%). Caucasian patients (P=.0013) and patients with vulvar dyplasia (P=.411) seemed to smoke more than other races and patients with cervical/vaginal dysplasia respectively., Conclusion: Smoking cessation counseling for the genital dysplasia patients who smoked was associated with smoking cessation in 32% of the patients., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The aim was to evaluate antitumor activity of the combination of ixabepilone and sunitinib in pre-clinical models of chemotherapy naïve and refractory epithelial ovarian tumors, and to investigate the mechanism of synergy of such drug combination., Methods: HOVTAX2 cell line was derived from a metastatic serous papillary epithelial ovarian tumor (EOC) and a paclitaxel-resistant derivative was established. Dose response curves for ixabepilone and sunitinib were generated and synergy was determined using combination indexes. The molecular mechanism of antitumor synergy was examined using shRNA silencing., Results: The combination of ixabepilone and sunitinib demonstrated robust antitumor synergy in naïve and paclitaxel-resistant HOVTAX2 cell lines due to increased apoptosis. The GTPase, RhoB, was synergistically upregulated in cells treated with ixabepilone and sunitinib. Using shRNA, RhoB was demonstrated to mediate antitumor synergy. These results were validated in two other EOC cell lines., Conclusions: Ixabepilone plus sunitinib demonstrated antitumor synergy via RhoB in naïve and paclitaxel-resistant cells resulting in apoptosis. This study demonstrates a novel mechanism of action leading to antitumor synergy and provides 'proof-of-principle' for combining molecular targeted agents with cytotoxic chemotherapy to improve antitumor efficacy. RhoB could be envisioned as an early biomarker of response to therapy in a planned Phase II clinical trial to assess the efficacy of ixabepilone combined with a receptor tyrosine kinase inhibitor such as sunitinib. To the best of our knowledge, this is the first demonstration of antitumor synergy between these two classes of drugs in EOC and the pivotal role of RhoB in this synergy., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: To identify factors that may contribute to poor sensitivity of anal cytology in contrast to the sensitivity of anoscopy in heterosexual women., Methods: We analyzed 324 patients with biopsy confirmed diagnosis of genital intraepithelial neoplasia (either vulva, vaginal, or cervical) from 2006 to 2011 who underwent both anal cytology and anoscopy. Cytology, anoscopy, and biopsy results were recorded. Biopsy specimens underwent independent analysis for quality of specimen. Also, biopsy specimens were analyzed for characteristics that may contribute to correlation, or lack thereof, between anal cytology and anoscopic directed biopsy., Results: 133 (41%) patients had abnormal anoscopy and underwent directed biopsy. 120 patients with normal anal cytology had anoscopy directed biopsies, resulting in 58 cases of AIN (sensitivity 9.4%; 0.039-0.199). This cohort was noted to have extensive keratosis covering the entire dysplastic anal lesion. 18 patients yielded abnormal anal cytology. Of these patients, 13 had anoscopic directed biopsies revealing 6 with AIN and absent keratosis (specificity 88.6%; 0.78-0.95). The κ statistic for anal cytology and anoscopy was -0.0213 (95% CI=-0.128-0.086)., Conclusion: Keratosis reduces the sensitivity of anal cytology. Furthermore, anal cytology poorly correlates with anoscopy in the detection of AIN (κ statistic=-0.0213)., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objective: Physicians in training are commonly evaluated on their medical knowledge and clinical skills but rarely in work efficiency. We developed a Resident Efficiency Score (RES) to study the clinical productivity and efficiency of residents., Methods: Physician Post Graduate Year (PGY) 1, 2, 3 and 4 trainees rotating on the gynecologic oncology service recorded their clinical work (using the Relative Value Units (RVU) and Medicare 1997 Evaluation and Management guideline) and their working hours. RES was calculated using total RVU per work hour logged (RES=RVU/hour)., Results: From July 1, 2007 to June 31, 2008, 36 residents rotated thru the gynecologic oncology service and were included in the study The residency included 23 female and 13 male residents, consisting of 23 Caucasians, nine African Americans, two East Indians, one Hispanic and one Iranian. These residents, under the supervision of three gynecologic oncology faculty members, evaluated 1,168 new, 7,011 clinic and 1,568 hospital patients during the study period. Residents' average weekly hours were similar: PGY 1 (55), PGY 2 (53.5), PGY 3 (60.5), PGY 4 (53.4) (p= 0.88). Overall resident work efficiency increased from PGY 1 (RES 4.4) to PGY 2 (RES 5.6) to PGY 3 (RES 6.2), and regressed in PGY 4 (RES 5.2) (p=0.04). Work efficiency was similar among all PGY years in the operating room (p=0.5) and on the weekend (p=0.18)., Conclusion: In this study, resident physicians worked more productively up to the third year and then regressed. RES may be a useful tool in helping resident to evaluate their clinical work efficiency.

Objectives: We studied medical student evaluation of their Obstetrics and Gynecology faculty defined as Teaching Effectiveness Score (TES). We also evaluated the role of sharing TES to all faculty transparently in enhancing teaching interest among faculty., Methods: Students evaluated faculty with questions: Which faculty enhanced or least aided your learning and why? The TES was calculated by adding the number of positive comments, subtracting the negative comments, and dividing this total by the amount of students on the rotation. TES was distributed to all attending physicians via email allowing faculty to see each other's evaluaton., Results: 203 third-year medical students evaluated 25 attending physicians. The median TES was 3.2 percent (range -0.4 to 100 percent) with two attending physicians scoring high (p<0.01). A trend test showed the change was quadratic: the faculty's TES increased initially then decreased over time (p=0.053 to 0.409). A high TES is associated with teaching awards. High TES is not associated with age (p=0.77), academic rank (p=0.71), gender (p=0.89), race (p=0.55)., Conclusion: TES measured teaching effectiveness as perceived by students. Transparency of TES induced interests in teaching initially but then declined with time.

Objective: Cancer patients have increased risks of leg deep venous thrombosis (DVT). We studied the incidence, risk factors and most predictive symptoms of leg DVT in gynecologic oncology patients., Study Designs: Gynecologic oncology patients with any leg DVT symptoms were recruited and screened using Doppler sonogram. All hospitalized surgery and non-ambulating patients received thigh-high sequential compression devices (SCDs) without heparin as a prophylactic method against thrombosis. Statistical analysis was done using chi-square or Fisher's exact tests., Results: Out of 1974 patients, 134 complained of lower limb symptoms. Doppler studies found 38 patients with leg DVT. Incidence of leg DVT was 36/853 (4.2%) in patients with cancer and 2/1121 (0.2%) in patients without cancer (odds ratio 2.8 with a diagnosis of cancer). Leg edema, erythema, fever, and warm leg were significant symptoms in diagnosing leg DVT (p<0.01). The cost of finding a leg DVT was $747.54., Conclusions: Clinical exam is less accurate than Doppler sonogram in diagnosing leg DVT. The incidence of leg DVT using SCD seems to be comparable with other studies. Finally, the cost of identifying leg DVT seems reasonable.

Objective: Higher number of lymph nodes counts may suggest a more accurate cancer staging. We wish to study whether sending lymph nodes to pathologist in four containers, instead of a single container, yields a higher nodal count., Methods: Patients with uterine cancer who underwent abdominal hysterectomy and lymphadenectomy were recruited. The right and left pelvic lymph nodes were collected from four locations (common, external and internal iliac, and obturator). Blinded randomization ex vivo allocated the side of the pelvic nodes specimen which was sent to pathology as one versus four containers. Each patient served as her own control by having the other side of her pelvic nodes sent as four different specimens. The surgeons and pathologists were blinded., Results: 104 consecutive patients were enrolled. The average age was 61 years old. The patients were predominately Caucasians (69%). The average total pelvic and aortic nodes per patients was 17.8. 54 patients, whose right-sided pelvic nodes were randomized to be sent in a single container, yielded an average of 7.2 right pelvic nodes versus 8.6 left pelvic nodes (p=0.026). 50 patients, whose left-sided pelvic nodes were randomized to be sent in a single container, yielded an average 8.1 right pelvic nodes versus 6.9 left pelvic nodes (p=0.042)., Conclusion: The lymph nodes count are higher when surgical nodes were sent as multiple separated instead of single specimens, regardless of the side of the pelvis.

Objective: The medical records, death certificates, and autopsy reports of patients have important medical, legal, and economic implications. This study evaluated the discrepancy between premortem diagnoses (as documented in the medical record and on death certificates) and postmortem diagnoses in a cohort of gynecological cancer patients., Methods: The records of all patients with a diagnosis of gynecological cancer who were followed by the Department of Obstetrics and Gynecology at the University of Texas Medical Branch and who died between January 1, 1988 and January 1, 2000 were evaluated. All patients who were admitted initially to Obstetrics and Gynecology service were included, even if they were transferred to a different service after admission. Patients with incomplete charts or in which the death certificate could not be obtained were excluded. The cause of death as recorded in the clinical progress note, death certificate, and autopsy was examined. Each record was evaluated independently by two of the authors to document the cause of death for each patient. The immediate and underlying causes of death were recorded., Results: One hundred and seventy eight OB/GYN patients died in the Hospital within the study period. Twelve charts were incomplete or the death certificates could not be identified. The majority of the deaths (91%) occurred on the Gynecologic Oncology service of which 29% (44/151) underwent postmortem examination. All patients in this subgroup had diagnosis of gynecologic malignancy. Twelve patients died while admitted to the Obstetrics service of which 7 underwent autopsy, and 3 patients died while admitted to the Gynecology service of which one patient underwent postmortem examination. The immediate cause of death was most commonly due to sepsis. We found a 66% discrepancy rate between the cause of death recorded in the medical record and/or death certificate and the postmortem diagnosis., Conclusions: Multiple studies have documented significant discordance between the medical record, the death certificate, and the postmortem diagnosis in reporting the cause of death. Our findings further confirm the importance of the postmortem examination in determining an accurate cause of death.

Background: We evaluated a patient's understanding of his or her cancer (diagnosis, location, stage, status) as a function of age, race, education, income, and marital status., Methods: Patients with cancer were prospectively recruited and surveyed during their outpatient chemotherapy. Survey questions related to demographics, cancer status, location of cancer, stage of disease, prescribed treatment, the treating oncologist, and satisfaction with both the oncologist and medical staff. Each patient's answers to the survey questions were then compared with his or her medical chart. Data analysis was performed with the Chi-square test, logistic regression, and multivariate analysis., Results: Study participants included 284 patients (38% male, 62% female) (56% African American, 42% Caucasian, 3% others) with a median age of 62 years. Patients correctly answered in regards to their diagnosis (98%), cancer location (91%), and name of their doctor (99%). However, only 23% scored correctly when asked the stage of their cancer. In univariate analysis, younger age (P = 0.006) was the only significant variable in answering the question correctly, while higher income (P = 0.065) and female gender (P = 0.092) approached statistical significance. In multivariate analysis, all three variables were shown to be significant (P values of 0.016, 0.028, and 0.041, respectively). Increasing age resulted in a reduction of 2.5% per year, higher income resulted in an increase of 1.3% per 1000 dollars, and females were 49% more accurate, in the ability to correctly identify the cancer stage., Discussion: Although patients seem to know their condition well, many of them do not understand the stage of their cancer. Older patients, patients with lower income, and male patients seem to have less understanding of the stage of their cancer.

Objective: Nutritional evaluation of cancer patients may lead to treatment intervention that reduces morbidity and mortality. This evaluation can be done subjectively or objectively. We studied the correlation between subjective and objective nutritional assessment in gynecological oncology patients., Methods: Sixty-seven consecutive patients admitted to the gynecological oncology service were prospectively evaluated by laboratory criteria using a standardized formula. The prognostic nutritional index (PNI) consists of tests measuring albumin, transferrin, triceps skin fold, and skin sensitivity reaction to common antigens. The patients were also subjectively evaluated using a standardized questionnaire and physical examination, known as the subjective global assessment, by two clinicians who were blinded from the PNI results. Both scores were categorized as normal, mild malnutrition, or severe malnutrition. Reproducibility of the subjective testers and consistency between the subjective and the objective evaluations were assessed with a weighted kappa statistic., Results: Cancer distribution consisted of 39 (58%) cervical, 16 (24%) endometrial, 11 (16%) ovarian, and one (2%) vulvar carcinomas. There was a high level of agreement between the two subjective raters (weighted kappa = 0.797; 95% CI 0.67-0.92). Furthermore, there were no cases in which the ratings differed by two points on the three-point ordered scale of nutritional status. Agreement between the two evaluation methods was only fair to moderate (weighted kappa = 0.435; 95% CI 0.28-0.59). Agreement was exact in 38 of 67 patients (57%). There were eight patients (12%) where the difference in ratings differed by two points on the ordinal scale, all with the subjective scored as normal, but the objective rated as severe malnourishment., Conclusion: In assessing nutritional status of gynecological patients, subjective assessment differs with objective/laboratory measurement.

Objective: This study evaluates the influence of a weekly tumor conference on the management of patient care in a gynecologic oncology service., Methods: The study utilizes all patients discussed in the gyncologic oncology tumor conference at the University of Texas Medical Branch (UTMB) from January 1, 1998, to January 1, 2001. Patient's information (age, race, cancer site, stage, new cancer versus recurrent) was abstracted from the minutes and attendant log of the tumor board. We compared the pathology and diagnosis for each patient as stated both before and after presentation at the tumor board. A discrepancy is defined as a change in tumor site, stage, or treatment, resulting from findings discussed at tumor board meetings. Major discrepancy is defined as changes that affect patient care. Minor discrepancy is defined as changes that do not affect patient care., Results: During the study period, a total of 459 cases were discussed (391 new cancer, 68 recurrent cancer). At each tumor conference, we discussed a mean of 3.7 cases (range 1-9, standard deviation 1.68). Thirty-two cases (6.9%) showed discrepancies with 23 major discrepancies and nine minor discrepancies. As a result of the tumor board, the two most common therapeutic changes were the addition of chemotherapy and surgery., Conclusions: In this study, a gynecologic oncology tumor board added clinical information available to pathologists, thereby alters final diagnosis and affects patient medical care.

Objectives: We wish to determine how well female obstetrics and gynecology (OB/GYN) residents in the United States follow recommendations for routine Pap smears in managing their own health care and to identify the reasons for noncompliance., Methods: A survey was mailed to 1693 female OB/GYN residents in the U.S. Factors associated with noncompliance were determined by chi-square. Logistic regression analysis was used to identify independent prognostic factors and calculate the odds ratio (OR)., Results: Six hundred eleven (36%) surveys were returned with compliance information. Noncompliance was reported by 33%. Lack of time or inconvenience was cited as the most common reason (93%) for noncompliance, followed by consideration of themselves as low risk for cervical disease (41%) and fear of or embarrassment in seeing a doctor (14%). On multivariate analysis, independent risk factors for noncompliance during residency included noncompliance prior to residency (OR 4.6, P<0.0001) and Asian ethnicity (OR 2.1, P = 0.02), whereas East Indian ethnicity (OR 3.0, P = 0.06) and having no children (OR 1.6, P = 0.07) were near significant., Conclusions: A substantial proportion of female OB/GYN residents do not follow standard recommendations for routine Pap smears. Although the principal reason for noncompliance given was lack of available time and/or inconvenience during residency, this behavior predated residency and was associated with specific ethnic groups.

Objective: To determine which hydration (saline, saline + mannitol, or saline + furosemide) is associated with least cisplatin nephrotoxicity., Methods: We randomized 49 women who received cisplatin (75 mg/m(2) every 3 weeks) into one of the three hydration arms. The 24-h creatinine clearance was measured before and on day 6 after cisplatin infusion. The patients of each arm received 2 l of saline hydration. In the saline + furosemide arm, 40 mg of furosemide was given after hydration. In the saline + mannitol arm, 50 g of mannitol was mixed with the cisplatin., Results: For the first cycle of chemotherapy, 15 women were randomized to saline, 17 to saline + furosemide, and 17 to saline + mannitol. For each group, the creatinine clearances before cisplatin infusion were (means+/-SD, milliliters per minute) 84.5+/-26.8, 82.5+/-24.0 and 87.4+/-25.6, and after cisplatin infusion were 79.1+/-31.9, 68.7+/-21.5, and 56.4+/-22.9, respectively. The decreases in creatinine clearance were similar between the saline group and the saline + furosemide group ( P=0.66), but different between the saline + mannitol group and the saline group ( P=0.02) or the saline + furosemide group ( P=0.02). As each woman received multiple courses of cisplatin, 15 who received saline contributed 41 paired datasets, 17 who received saline + furosemide contributed 49 paired datasets, and 17 who received saline + mannitol contributed 36 paired datasets showed similar patterns., Conclusions: Hydration with saline or saline + furosemide appears to be associated with less cisplatin nephrotoxicity than saline + mannitol.

Objective: This study assesses cytology to evaluate the endocervical canal immediately after loop excision., Material and Methods: In 103 patients, we performed a cytologic smear and endocervical curettage immediately after loop excision. Diagnoses were made independently by two cytopathologists and compared to histology. Diagnostic agreement was evaluated statistically., Results: Cytopathologist "A" found a sensitivity of 1.0, specificity of 0.9, positive predictive value (PPV) of 0.44 and negative predictive value (NPV) of 1.0. Cytopathologist "B" found a sensitivity of 0.88, specificity of 0.78, PPV of 0.3 and NPV of 0.98. There was good agreement between the two cytopathologists (kappa = 0.42, 95% CI = 0.25, 0.60). Twenty-five endocervical curettage specimens were insufficient for diagnosis. Seven and 4 cytology specimens were judged unsatisfactory by each cytopathologist, respectively. Histologic and cytologic evaluation charges were $283 and $60.50 per patient, respectively., Conclusion: The use of cytology efficiently evaluates the endocervical canal after loop excision.

Objective: The goal of this study was to evaluate the safety of hemodilution on global and splanchnic perfusion and blood coagulation during radical hysterectomy., Methods: A pulmonary artery catheter and a gastric tonometry catheter were placed in 16 patients with cervical carcinoma. Global perfusion indices, splanchnic perfusion index, and coagulation tests were obtained. Blood was removed to achieve a hemoglobin measurement of 8-9 9 g/dL. Three more measurements were repeated after hemodilution, at the end of surgery, and after the retransfusion of blood. Analysis of variance was used to determine statistical significance., Results: Sixteen patients with cervical carcinoma had 1.0 +/- 0.3 L (mean +/- SD) of blood removed and had a blood loss of 0.8 +/- 0.7 L. Hemodiluted preoperative hemoglobin was 8.7 +/- 1 g/dL. All of the global perfusion indices, except for arterial pH and oxygen consumption, decreased after hemodilution and recovered with the retransfusion of blood (P < or = 0.004). Splanchnic perfusion and coagulation tests were unchanged (P > or = 0.1). Major complication was pulmonary edema in one patient., Conclusion: Hemodilution during radical hysterectomy, in this select group of patients, does not appear to compromise tissue perfusion or coagulation., (Copyright 2001 Academic Press.)

Objective: The aim of this study was to evaluate additional error in estimating red cell loss during abdominal hysterectomy., Methods: Eighty patients admitted consecutively for abdominal hysterectomy were recruited. The surgeries were done after heparinizing the suction tubing system to prevent clotting and reducing the vacuum pressure to reduce red cell lysis. At the end of the surgery, hematocrit was measured and compared with the patient's venous blood and the blood from the suction container. The Mann-Whitney test evaluated statistical significance., Results: Eight patients were excluded for having a hemolyzed blood sample, receiving a blood transfusion, and having incomplete data. The study cohort consisted of 72 patients: 54 had a simple hysterectomy and 18 had a radical hysterectomy with pelvic and periaortic lymphadenectomy. The hematocrit (mean +/- standard deviation) in the suction container (19.8 +/- 8.8%) was lower than the hematocrit from the venous blood sample (32.4 +/- 6%) (P < 0.001). The hematocrit in the suction container decreased as the duration of the surgeries increased. Although the volume of blood in the suction container was used to estimate blood loss, the concentration of red cells in the container was consistently lower than those in the venous blood sample. The magnitude of dilution increased as the length and radical nature of the surgery increased., Conclusions: These findings suggest that other fluid, probably lymph, contributes to the dilution of red cells in the container and increases the estimated blood volume loss during surgery. Estimation of red cell surgical blood loss becomes less accurate as the length and radical nature of the surgery increase., (Copyright 2001 Academic Press.)

Ovarian cancer arises from the accumulation of mutations in multiple combinations of genes (1). The most extensively studied tumor suppressor gene in solid tumors is p53, a 53-kD nuclear phosphoprotein that binds DNA. The p53 gene product plays a role in normal cellular proliferation by regulating gene transcription, cell cycle control, and apoptosis (2). Mutations of p53 are the most common molecular genetic abnormality to be described in human cancer, and have been identified in malignancies of the breast, colon, lung, esophagus, head and neck, and hematopoietic system (3). Mutations of the p53 gene have been identified in 30 to 79% of epithelial ovarian cancers (4,5). Most of the mutations identified in p53 are distributed throughout the open reading frame as missense mutations. We have identified a missense mutation in the p53 gene in the 2774 ovarian cancer cell line that converts an arginine residue in the DNA binding region of the protein to a histidine residue (6). The mutation in codon 273 we found in 2774 cells is one of the six major hotspots identified for p53 missense mutations (7).

Carcinoma of the vulva is an uncommon gynecologic malignancy primarily affecting postmenopausal women. The lesion is most commonly associated with HPV DNA, although, for many, a defined preinvasive to invasive connection is not readily apparent. Most patients experience symptoms of pruritus, irritation, and even pain for weeks or months before the diagnostic biopsy is performed. Patient embarrassment and unfamiliarity and reluctance on the part of the physician to fully evaluate these symptoms add to the delay. Vulvar carcinoma is staged surgically following resection. A concerted effort to conserve as much normal tissue as possible has been the focus of recent investigation. Separate incision resection of the vulvar mass and groin has improved wound healing and quality of life for many patients. The effect these conservative procedures have on long-term survival is currently being evaluated. Increased use of radiation therapy or chemoradiation has allowed organ preservation in many otherwise exenterative cases. In some instances, this neoadjuvant therapy has provided an opportunity to surgically clear otherwise unresectable lesions. Current radiotherapy techniques might also be as effective as groin dissection in certain low-risk patients. Adjuvant radiation and chemoradiation improve local control and reduce groin recurrence risk. In addition, patients with histologically positive groins enjoy longer survival when the pelvis is also treated. Selected use of multimodality therapy will likely extend the lives of women with vulvar cancer.

Objective: To study the histologic regression and progression rates of cervical intraepithelial neoplasia (CIN) II and III after delivery and the effect the route of delivery has on the regression rates of CIN., Methods: Pregnant patients with satisfactory colposcopic examinations and biopsy-proven CIN II and III were identified. Delivery information and postpartum biopsy results were obtained by chart review., Results: Two hundred seventy-nine patients had antepartum biopsies of CIN II or CIN III. Of these, 126 women were excluded for the following reasons: lost to follow-up (75), human immunodeficiency virus positive (two), cesarean hysterectomy (four), and inadequate postpartum follow-up (45). This yielded a study group of 153 patients consisting of 82 with CIN II and 71 with CIN III. The regression rates were 68% and 70% among CIN II and CIN III patients (P = .78), respectively. Seven percent of patients with CIN II progressed to CIN III on postpartum evaluation. Twenty-five percent of those patients with CIN II and 30% of those with CIN III remained the same postpartum. No CIN lesions progressed to invasive carcinoma. There were no differences in regression rates or progression rates among the women who had vaginal deliveries (130), women who labored and then underwent cesarean (17), or women who proceeded to a cesarean without laboring (six)., Conclusion: We found similar high postpartum regression rates despite the route of delivery. We recommend conservative antepartum management with postpartum colposcopic evaluation regardless of route of delivery because we are unable to predict which of these lesions are more likely to regress.

Objective: Glutamine is proposed to protect bowel from radiation. However, glutamine may decrease cancer's radiosensitivity. We evaluate glutamine's effect on the growth rate and radiosensitivity of two cervical carcinoma cell lines in vitro., Methods: HeLa and CaSki cells were seeded at 3000 cells/well in glutamine-free medium. An increasing amount of glutamine (0.4, 10, and 20 mM) was added to the respective plates, incubated, and irradiated with a single fraction of 0.5, 1, 3, and 6 Gy. Using a growth inhibition assay and photometric analysis, the viable cells were counted on day 8. Cell counts represent a mean +/- standard deviation from six experiments and are expressed in 10(3) cells. Analysis of variance was performed., Results: In nonirradiated HeLa plates, absence of glutamine results in 5.7 +/- 1.2 cells/well. Addition of glutamine at 0.4, 10, and 20 mM to nonirradiated cells significantly (P < 0.0001) increased growth to 79.1 +/- 10.0, 122.5 +/- 9.0, and 114.3 +/- 13.9 cells/well, respectively. In culture plates irradiated with 6 Gy, HeLa cells supplemented with 0.4, 10, and 20 mM of glutamine showed lower cell counts (P < 0.008). A similar significant growth suppression at 6 Gy in comparison to 0.5, 1, and 3 Gy was observed (P < 0.01). CaSki cells showed similar patterns., Conclusions: Growth of HeLa and CaSki cells in vitro requires a minimum of 0.4 mM of glutamine in the medium. Supraphysiologic glutamine concentration does not increase tumor growth or radioresistance. Glutamine should be evaluated further as a potential bowel radioprotector., (Copyright 1998 Academic Press.)

Objectives: To compare gastric tonometry (pHi) with estimates of pHi in ill injured patients, and to correlate pHi with haemodynamic variables., Design: Prospective, non-interventional study., Setting: ICU of Level I trauma centre, USA., Main Outcome Measures: 154 gastric tonometry measurements were compared with physicians' estimates of adequacy of resuscitation. Resuscitation was categorised as inadequate (pHi < 7.35) or adequate (pHi> or = 7.35). Measured and estimated pHi were also compared with oxygen delivery, oxygen consumption, cardiac index, mixed venous O2 saturation, and critical illness scores., Results: Estimated pHi was often higher than measured pHi in the judgement of all four surgical intensive care physicians. Measured pHi correlated positively with mixed venous O2 tension (r = 0.21). There were significant negative correlations between measured pHi and both oxygen delivery (r = -0.25) and oxygen consumption (r = 0.28). Estimated pHi correlated positively with mean arterial pressure (r = 0.21) and hospital day (r = 0.26); it correlated negatively with pulmonary arterial elastance (r = -0.35)., Conclusion: Experienced intensive care physicians tended to overestimate visceral perfusion, which suggests that gastric tonometry adds useful information over and above routine haemodynamic indices. Arterial blood pressure and mixed venous oxygen saturation correlated better with measured pHi than with other indices of perfusion.

Objectives: To test the safety, efficacy, and toxicity of gene therapy using wild-type p53-expressing adenovirus (Ad-CMV-p53) in a nude mouse model with intraperitoneal (i.p.) 2774 human ovarian cancer cell line that contains a p53 mutation., Study Design: An initial study of adenovirus tolerance was determined in nude mice by a single i.p. injection of increasing doses of Ad-CMV-p53. Nude mice were implanted with an LD100 dose of 1 x 10(7) cells. To study the efficacy and specificity of Ad-CMV-p53 treatment, the mice received treatment with different adenovirus constructs. One group received Ad-CMV-p53 and another group received a control adenovirus construct, Ad-CMV-beta gal. To study the treatment response to Ad-CMV-p53, the mice were divided into groups and received various treatment schedules of 1 x 10(8) pfu of Ad-CMV-p53., Results: The mice tolerated Ad-CMV-p53 without adverse effects at doses of 1 x 10(8) pfu. The response to Ad-CMV-p53 showed significant survival duration in each dose regimen, with a survival time greater than that of untreated animals (P = 0.0173). However, no statistically significant survival advantage was observed between Ad-CMV-p53- and Ad-CMV-beta gal-treated mice., Conclusions: These studies show that at the adenovirus dose and administration regimen used, there is effective but not specific 2774 tumor growth inhibition in vivo. Efficient introduction of biologically active genes into tumor cells would greatly facilitate cancer therapy. Thus, although promising, these results caution that much effort will be required to realize the potential for clinical application of adenovirus-based ovarian cancer gene therapy.

Objective: To analyze the diagnostic accuracy and alteration in treatment planning from interinstitution (different institution) pathologic consultation., Methods: We reviewed pathologic reports from 720 referred patients. The diagnosis rendered from a gynecologic pathologist was compared with the original diagnosis. Discrepancies were coded as none, minor, or major. A discrepancy was major if it led to treatment alteration. A discrepancy was minor if it did not lead to treatment alteration. The judgment to declare a discrepancy was made by a gynecologic pathologist, a gynecologist, and three gynecologic oncologists. The review cost was $150 per case. The Cochran-Mantel-Haenszel test evaluated any systematic pattern in discrepancies., Results: Seven hundred twenty specimens consisted of 113 vulvar, 170 uterine, 289 cervical, 105 ovarian, and 43 vaginal tissues. Six hundred one (84%) pathologic diagnoses showed no discrepancy. There were 104 (14%) minor and 15 (2%) major discrepancies. After reviewing 15 major discrepancies, six surgeries were canceled, two surgeries were modified, one adjuvant radiation treatment was added, one chemotherapy treatment was modified, and five adjuvant chemotherapy treatments were cancelled. No systematic error was identified with regard to the sources (tissue origin) or methods of obtaining the specimen (P = .675). The cost of reviewing 720 specimens was $108,000. The cost of identifying each major discrepancy was $7200., Conclusion: Reviewing pathology slides before definitive treatment reveals notable discrepancies in diagnoses. The cost of pathology review is globally expensive but has consequential impact on proper treatment planning for the individual patient.

Mutations of the p53 tumor suppressor gene are the most common molecular genetic abnormality to be described in ovarian cancer. To determine the feasibility of mutant p53 as a molecular target for gene therapy in ovarian cancer, we constructed an adenovirus vector containing the wild-type p53 gene. The ability of this adenovirus construct (Ad-CMV-p53) to express p53 protein was examined by Western blot analysis in the H358 lung cancer cell line, which has a homozygous deletion of the p53 gene. The ability of the adenovirus vector system to infect ovarian cancer cells was tested using an adenovirus containing the beta-galactosidase reporter gene under the control of the CMV promoter (Ad-CMV-beta gal). The ovarian cancer cell line 2774, which contains an Arg273His p53 mutation, was infected with Ad-CMV-beta gal, and the infected cells were assayed for beta-galactosidase activity after 24 hr. To test the ability of wild-type p53 to inhibit cell growth, the 2774 cell line was infected with Ad-CMV-p53 or Ad-CMV-beta gal, and the effect of these agents on the growth of 2774 cells was determined using an in vitro growth inhibition assay. Western blot analysis of lysates from H358 cells infected with Ad-CMV-p53 showed expression of wild-type p53 protein. When 2774 cells were infected with Ad-CMV-beta gal at a multiplicity of infection (m.o.i.) of 10 PFU/cell, > 90% of cells showed beta-galactosidase activity, demonstrating that these cells are capable of efficient infection by the adenovirus vector. Growth of 2774 cells infected with Ad-CMV-p53 was inhibited by > 90% compared to noninfected cells. The ability of the adenovirus vector to mediate high-level expression of infected genes and the inhibitory effect of Ad-CMV-p53 on the 2774 cell line suggests that the Ad-CMV-p53 could be further developed into a therapeutic agent for ovarian cancer.

Obstetricians and Gynecologists care for many patients with conditions potentially requiring blood transfusions. Cesarean section and hysterectomy are the two surgeries performed most frequently and both have the potential for blood loss requiring transfusion. Other examples include postpartum hemorrhage, placenta previa, and ruptured ectopic pregnancy. Obstetricians and gynecologists need to become knowledgeable about the ever-changing aspects of blood transfusion and apply it in their clinical practice. This review intends to update obstetricians and gynecologists and other health care professionals about the basic as well as the latest technologies of blood transfusion. The different types of blood components are discussed including their preparation, indications, risks, and benefits. The complications of blood transfusion and their management are reviewed, including infections, noninfectious, and immunological etiologies. HIV and hepatitis are explored, these being the most serious infectious risks of transfusion. Autologous blood transfusion, an underutilized option, is examined. Hemodilution and intraoperative blood salvage, other techniques for using the patient's own blood, are discussed. Finally, synthetic agents such as erythropoietin, granulocyte colony-stimulating factors, factors, desmopressin acetate, gonadotropin-releasing hormone agonists, and new products are introduced as potential replacements to blood transfusion in the future.

Primary malignant cervical melanoma is diagnosed by the presence of junctional melanocytic abnormality and the absence of distant metastasis. Amelanotic and poorly differentiated tumors can often be diagnosed with the HMB-45 immunoperoxidase stain which is very specific for melanoma. Early reported cases were treated with simple excision followed many times by radiation therapy. Radical hysterectomy, pelvic lymphadenectomy, and partial vaginectomy have been advocated by some contemporary investigators. Radiation can be used as adjuvant or palliative treatment; its efficacy is not well established. Few patients have been treated with modern chemotherapy. No patient has been treated with immunotherapy. Primary malignant cervical melanoma carries a very poor prognosis. Most patients succumb from their disease within 2 years. One patient has survived 14 years. The small number of reported cases makes it difficult to evaluate the efficacy of any treatment modality.