摘要:

Objectives:To present six additional cases of gynecologic tumors in tamoxifen-treated breast cancer patients, review the literature, and recommend measures for surveillance.Methods:The hospital and office records of patients treated with tamoxifen at the University of Kansas Medical Center and Research Medical Center were analyzed. A comprehensive review of tamoxifen in the English and European literature was performed using MEDLINE and the bibliographies of various articles.Results:From 1985-1992 at our institutions, six tamoxifen-treated breast cancer patients developed gynecologic tumors: three endometrial adenocarcinomas, a mixed müllerian sarcoma, a fallopian tube carcinoma with adenofibroma of the endometrium, and recurrent hyperplastic endometrial polyps. The literature contained 61 cases of adenocarcinoma of the endometrium and possibly four cases of uterine sarcomas in tamoxifen-treated breast cancer patients. The number of gynecologic malignancies reported is now 70. In 35 of the patients, the mean age (± standard deviation) was 63.9 ± 12.0 years, and 61 of 66 patients (92.4%) were postmenopausal. Of the endometrial adenocarcinomas, 25 of 27 (92.6%) were stage I, and 11 of 27 (40.7%) were grade 1. The dose of tamoxifen was 20 mg/day in 15 mg/day in 11 (17.2%), and 40 mg or higher in 38 (59.4%); 57% were treated with tamoxifen for less than 2 years.Conclusions:Tamoxifen is a safe and reliable treatment of breast cancer, but data suggest an association with endometrial cancer. We propose close monitoring of patients taking tamoxifen and prompt evaluation of any uterine bleeding or pelvic complaint. (Obstet Gynecol 1993;82:165-9) n 15 (23.4%), 30 mg/day in 11 (17.2%) and 40 mg of higher in 38 (59.4%) were treated with tamoxifen for less than 2 years.Conclusions:Tamoxifen is a safe and reliable treatment of breast cancer, but data suggest an association with endometrial cancer. We propose close monitoring of patients taking tamoxifen and prompt evaluation of any uterine bleeeding or pelvic complaint.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objective:To determine the effect of human immunodeficiency virus (HIV) infection on the rate of recurrence of cervical intraepithelial neoplasia (CIN) after standard ablative therapy, and to correlate the degree of immunosuppression with treatment results.Methods:The clinical courses of 44 HIV-positive women with CIN were compared with those of 125 HIV-negative women. Patients were treated with cryotherapy, laser therapy, or cone biopsy per standard indications and were followed with cytology at regular intervals, with a range of follow-up of 3-43 months.Results:Seventeen of 44 HIV-positive women (39%) developed biopsy-proven recurrent CIN, compared to 11 of 125 HIV-negative women (9%) (P< .01). The distributions of CIN severity, lesion size, and modality of treatment were similar in the two groups. In HIV-negative patients, recurrent CIN was associated with increasing grade, but in HIV-positive patients, recurrence was related to increasing immunosuppression. The mean CD4 count in HIV-positive patients with recurrence was 239/mm3, compared to 367/mm3in HIV-positive patients who remained free of CIN. Only 18% of HIV-positive patients with CD4 counts over 500/mm3had recurrence, compared to 45% of those with CD4 counts under 500. There was a trend toward poorer treatment results with the use of cryotherapy in HIV-positive patients. All recurrences occurred in patients whose mode of acquisition of HIV was heterosexual transmission.Conclusion:Recurrence rates of CIN after standard treatment in HIV-positive women are high, and recurrence is related to immune status in this high-risk group. Therapeutic strategies that address these treatment failures should be developed for HIV-seropositive women.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objective:To determine whether using a treatment strategy minimizing lymph node sampling and radiation therapy compromised outcome in patients with early endometrial carcinoma.Methods:One hundred three consecutive patients with International Federation of Gynecology and Obstetrics surgical stage I, II, or III endometrial carcinoma were treated with primary surgery followed by tailored adjuvant radiation therapy using a strategy designed to minimize lymph node sampling and whole pelvic radiation. Para-aortic lymph node dissection was performed only among patients with high-risk factors such as high-grade tumors, deep myometrial invasion, or stage II or III disease. Postoperative radiation therapy was tailored to the surgical and pathologic findings. Treatment with whole pelvic radiation was limited to patients with at least one of these high-risk factors.Results:Thirty-four patients underwent para-aortic node dissection. Thirty-six patients received no adjuvant radiation therapy; 19 received vaginal radiation and 47 received whole pelvic radiation. Ninety-three patients (90%) have had no tumor recurrence during a median follow-up period of 30 months (range 8-96). Analysis of the recurrence pattern indicates that more aggressive use of lymph node evaluation or radiation therapy would not have lowered the recurrence rate. All of the patients who had recurrence were identified as high-risk and received aggressive therapy. Furthermore, the pattern of recurrence suggests that many of these patients had occult distant disease at the outset of therapy.Conclusion:The data suggest that this selective approach does not compromise survival in patients with early-stage endometrial carcinoma. This management strategy has the advantage of confining the morbidity of lymph node dissection and radiation therapy to those patients at greatest risk for lymph node metastases and recurrence, respectively. Further improvements in survival await the development of effective systemic therapy.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objective:To correlate various types of hyperplastic lesions of the ovarian surface epithelium with primary disease the female genital tract.Methods:Using whole-organ multiple sections of ovary, we studied 200 hysterectomy and bilateral salpingooophorectomy specimens distributed into four groups: cases without hyperplastic or neoplastic disease in the tube, uterus, or vagina; those with contralateral epithelial ovarian tumors; those with endometrial adenocarcinomas; and those with polycystic ovary disease.Results:We found a high frequency of hyperplastic metaplastic changes in the surface epithelium or in inclusion cysts in ovaries with contralateral epithelial ovarian tumors (92%), endometrial adenocarcinomas (76%), polycystic ovary disease (68%) compared to ovaries without hyperplastic or neoplastic disease (22%). These changes were frequently associated with intracystic papillae psammoma bodies similar to those observed in epithelial tumors. The inclusion cysts were unrelated morphologically to signs of preceding ovulation, but were related to deep crypts of the ovarian epithelium and to stromal hyperplasia.Conclusions:The hyperplastic and metaplastic changes the surface epithelium and related inclusion cysts can considered morphologic precursors of common epithelial tumors. Similar changes are found as a response to hormonal ovarian or extraovarian stimulus, which may play an important role in ovarian carcinogenesis.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objective:To determine whether the ovaries should be retained or removed in premenopausal women undergoing radical hysterectomies for cervical carcinoma.Methods:Questionnaires were sent to all women who had radical hysterectomies without further therapy for cervical carcinoma at our institution over a 16-year period. Those who had retained ovarian tissue were asked to have serum gonadotropin levels measured.Results:Eighty-four of 124 eligible women (68%) responded. Sixty-eight respondents were premenopausal at the time of surgery. Thirty-eight had a bilateral salpingooophorectomy (BSO), 20 had one ovary preserved, and ten retained both ovaries. Six of 30 (20%) who retained ovaries developed early hormonal failure. Two of these 30 (7%) required oophorectomies subsequently. Twenty-seven of 38 BSO patients (71%) were compliant with their hormone replacement regimens. Fourteen of 15 women (93%) age 40 or younger were compliant, whereas 13 of 23 (57%) over age 40 were compliant (P< .05). Twenty-three of 34 BSO respondents (68%) reported improved or unchanged sexual relations, compared with 24 of 27 (89%) who retained ovaries (P> .05).Conclusions:Twenty-seven percent of our premenopausal women with retained ovaries have experienced early loss of hormonal function or required subsequent oophorectomies. For an accurate estimate of ovarian longevity, all patients would have to be followed through menopause. Compliance in taking hormone medication was high in our young patients. Sexual function was not adversely affected following castration. A hypothetical cost comparison favored removing, rather than retaining, the ovaries. We recommend that elective BSO be performed on most premenopausal women undergoing radical hysterectomies for cervical carcinoma.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objective:To evaluate the involvement of endogenous opiates in the pathophysiology of the hyperinsulinism in patients affected by polycystic ovary disease by administering naloxone and naltrexone. We also studied the hormonal status following long-term opioid antagonist administration.Methods:Twenty-one women affected by polycystic ovary disease participated in the study. An oral glucose tolerance test (GTT) was performed at baseline and repeated after short-term naloxone infusion and after 6 weeks of naltrexone administration. Plasma glucose and insulin levels were evaluated in all samples. Gonadotropins, sex hormone-binding globulin, and androgen levels were determined initially and after the naltrexone treatment.Results:None of the patients showed any alteration of glucose tolerance. Based on the insulin response to the GTT, the patients were classified as normo- or hyperinsulinemic. Opioid antagonist administration significantly reduced the insulin response to the GTT in hyperinsulinemic patients, without affecting their glycemic levels. In normoinsulinemic patients, glucose plasma levels were increased whereas insulin levels were not modified by the treatments. Gonadotropin and androgen plasma concentrations were not modified after naltrexone administration.Conclusions:This work supports a role for the endogenous opiates in the regulation of exaggerated insulin secretion in patients with polycystic ovary disease. The reduction of insulin secretion failed to demonstrate any hormonal modification in such hyperandrogenized patients.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objective:To compare the efficacy, endocrine effects, and safety of Zoladex (goserelin acetate) and danazol in the treatment of premenopausal women with endometriosis in a multicenter, randomized, open study.Methods:Three hundred fifteen patients with stages I-IV endometriosis (revised American Fertility Society [AFS] classification) were treated with Zoladex, 3.6 mg every 28 days by subcutaneous injection, or danazol, 400 mg orally twice daily for 24 weeks. Efficacy was assessed by determination of pelvic signs and symptoms scores and revised AFS endometriosis scores. Endocrine effects were determined by measurements of hormone levels. Safety was evaluated by physical examination, laboratory indices, occurrence of adverse events, and bone mineral density changes.Results:Both treatments significantly (P< .0001) reduced mean subjective signs and symptoms scores both during and after therapy. The mean percent reduction in the revised AFS endometriosis score after 24 weeks of treatment was 53% for Zoladex and 33% for danazol, and reduction in the endometrial implants score was 56% for Zoladex and 46% for danazol. Serum estradiol levels decreased to the postmenopausal range in the Zoladex group and to the early follicular phase range in the danazol group. Hypoestrogenic effects occurred more frequently with Zoladex, whereas androgenic side effects were more common with danazol. There was a higher percentage of withdrawals due to adverse events with danazol than with Zoladex. Mean bone mineral density decreased from baseline by 5.4% in the Zoladex group and increased by 1.0% in the danazol group at the end of treatment.Conclusion:Zoladex is as well tolerated and as effective as danazol in the treatment of premenopausal women with endometriosis.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objective:To investigate the immunosuppressive effect of peritoneal fluid and follicular fluid on both natural killer-mediated cytotoxicity and phytohemagglutinin-induced lymphocyte proliferation.Methods:The peritoneal fluid of women with endometriosis was compared to both fertile and infertile control fluids. Lymphocytes were pretreated for 2 or 20 hours with peritoneal or follicular fluids, and their cytotoxicity toward K562 tumor cells was measured. We also investigated the phytohemagglutinin-induced stimulation of lymphocytes co-cultured with peritoneal or follicular fluid.Results:Peritoneal fluid from women with endometriosis had a significantly greater immunosuppressive effect on natural killer-mediated cytotoxicity and on phytohemagglutinin stimulation of lymphocytes compared to peritoneal fluid of fertile women without endometriosis (P< .01 andP< .05, respectively). Using the peritoneal fluid of infertile women without endometriosis, these differences were significant only when compared to women with severe endometriosis. Inhibition of the natural killer activity increased when the incubation period was prolonged from 2 to 20 hours (P< .04). There was no correlation between the immunosuppressive effect of peritoneal fluid and the volume of peritoneal fluid, the day of the menstrual period, estradiol, progesterone, prostaglandin E2, or prostaglandin F2αlevels. In peritoneal fluid, the factor responsible for inhibition of natural killer activity was not removed with charcoal treatment. In follicular fluid, on the other hand, the inhibition of natural killer activity decreased significantly after treatment with charcoal.Conclusion:Natural killer activity is suppressed by the peritoneal fluid of women with severe endometriosis; this may be important in the pathogenesis of endometriosis. The factor responsible for the inhibition of natural killer activity in peritoneal fluid is different from that in follicular fluid.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objectives:To evaluate adhesion formation after myomectomy and the reproductive outcome of infertile women with a large leiomyomatous uterus after myomectomy and second-look laparoscopy.Methods:Twenty-six infertile women with a large leiomyomatous uterus underwent second-look laparoscopy 6 weeks after a myomectomy. At laparoscopy, the degree of adhesions was scored using the American Fertility Society classification of adnexal adhesions, and the adhesions were lysed. The pregnancy rates of these women were evaluated by life table analysis.Results:A myomectomy incision on the posterior wall of the uterus was associated with more adnexal adhesions than that on the fundus or anterior uterine wall (93.7 versus 55.5%;P= .04). The degree of adnexal adhesions was also higher among women who underwent myomectomy with a posterior uterine incision (22.2 ± 2.3 points) than in those with a fundal or anterior uterine incision (2.7 ± 1.2 points) (P< .000001). The cumulative pregnancy rate was 33.4% at 6 months and 66.7% at 12 months after the procedures.Conclusions:Myomectomy incisions on the posterior uterine wall are associated with more and a higher degree of adnexal adhesions than those on the fundus and anterior wall. Conception occurs in the majority of infertile women with a large myomatous uterus who undergo myomectomy and second-look laparoscopy.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID

摘要:

Objective:To determine the dose-response relationship of colchicine in reducing inflammatory adhesive disease secondary toNeisseria gonorrhoeaein the rabbit.Methods:Following intrauterine inoculation of a suspension ofN gonorrhoeae, the rabbits were divided into five groups of 11 rabbits each. The control group received no medications. The remaining four groups received 0.1,0.5,1, and 2 mg, respectively, of colchicine intramuscularly daily for 14 days. The day after the last injection of colchicine, the peritoneal cavity was explored and assessed for the presence, number, and grade of adhesions.Results:With increasing doses of colchicine, the incidence of adhesions decreased. A linear model (log [dose + 0.5]) showed, however, that as the dose of colchicine increased, the response tended to plateau (P< .05).Conclusion:In this model, colchicine was effective in preventing inflammatory adhesions in the rabbit. Increasing doses produced a greater effect in reducing adhesion formation. However, there was a plateau of the response at the 1-mg dose.

ISSN:0029-7844    

出版商:OVID    

年代:1993

数据来源: OVID