The value of preoperative platelet count in the prediction of cervical involvement and poor prognostic variables in patients with endometrial carcinoma

OBJECTIVE(S): To evaluate the relationship between preoperative platelet counts and prognostic factors extensively, among endometrial cancer patients, especially with respect to cervical involvement. METHODS: One-hundred fifty-five patients with endometrial carcinoma, who underwent surgery as the initial treatment consisting peritoneal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, systematic pelvic-paraaortic lymphadenectomy, and omentectomy were retrospectively analyzed. RESULTS: There were no differences with respect to age, histological type (endometrioid vs. non-endometrioid), depth of myometrial invasion, peritoneal cytology, LVSI, and lymphatic metastasis. However, advanced stage (stages III and IV), poorly differentiated tumor grade (grade 3), the presence of cervical and adnexal involvements were associated with significantly higher median preoperative platelet counts. Accepting 325.000/microl platelet count as a threshold value, multivariate analysis revealed cervical involvement (P=0.008; OR=1.84, 95% CI:1.17-2.89) and presence of high grade histology (P=0.014; OR=2.23, 95% CI:1.18-4.23, for grade 3 disease) to be significantly associated with higher platelet count. At a cut-off value of 326.000/microl, 42.3% sensitivity and 82.8% specificity for the prediction of cervical involvement was observed under receiver operator characteristic curve method. CONCLUSION(S): Higher preoperative platelet counts, even in conditions with normal range (150.000-400.000/microl), may reflect poor prognostic factors such as cervical involvement and high grade among patients with endometrial carcinoma. Also, the higher platelet count should be taken into consideration for the necessity of radical hysterectomy.     

Incidence and risk factors for postoperative venous thromboembolism in patients with ovarian cancer: Systematic review and meta-analysis

BackgroundVenous Thromboembolism (VTE) is a leading cause of morbidity and mortality in patients with ovarian malignancy. There is no meta-analysis available on this topic so far. The aim of our study was to quantitatively synthesize the data from studies with respect to the incidence and risk factors for postoperative VTE among cases with epithelial ovarian cancer (EOC).MethodsPubMed, Web of Science, and Embase were searched for papers containing the key words “venous thromboembolism”, “postoperative”, “postoperation”, “ovarian neoplasm”, “ovary neoplasm”, “ovarian cancer”, “ovary cancer”, and “cancer of ovary”. Studies selection, data extraction, quality assessment of eligible studies were performed independently by our different reviewers. Meta-analyses were conducted to determine postoperative VTE incidence and risk factors in women with EOC. Sensitivity analysis were used to verify the robustness of the results of meta-analyses if necessary.ResultsIn total, 19 studies were included in this meta-analysis. The pooled incidence for postoperative symptomatic VTE was 3% (95% CI, 0.03–0.04) and for postoperative symptomatic as well as asymptomatic VTE was 8% (95% CI, 0.07–0.09). The presence of history of VTE (OR, 2.37), advanced-stages (OR, 2.35), high complexity of surgery (OR, 2.20), clear cell carcinoma of ovary (OR, 2.53) and residual disease>1 cm (OR, 2.57) significantly increase the likelihood of having postoperative VTE. Other risk factors for postoperative VTE in EOC patients were BMI>30 (OR, 1.58), per 10-years increase in age (OR, 1.22), ASA score>2 (OR, 1.45), ascites (OR, 2.07), the diameter of residual disease is between 0 cm to 1 cm (OR, 2.06) and smoking history (OR, 1.54).ConclusionsThis study revealed that VTE, especially subclinical VTE, is a prevalent complication in postoperative patients with EOC. History of VTE, advanced FIGO stages, high complexity of surgery, obesity, older age, ascites, higher ASA score, smoking history and suboptimal debulking are associated with this increased incidence of postoperative VTE among patients with EOC.PROSPERO registration number: CRD42020209662.     

Retrograde seeding of malignant cells during hysteroscopy in presumed early endometrial cancer

OBJECTIVE: The aim of this study was to determine the effect that preoperative hysteroscopy has on the frequency of positive cytology at the time of definitive surgical management in endometrial cancer. METHODS: Charts of 222 patients with endometrial cancer were reviewed. Patients were divided according to whether (n = 64) or not (n = 158) they had hysteroscopy with saline infusion. Each group was stratified into low or high risk for positive peritoneal cytology. Logistic regression analysis was used to compare the prevalence of positive peritoneal cytology with and without hysteroscopy, before and after the stratification, adjusting for the confounding risk factors. RESULTS: After adjusting for confounding variables there was a statistical difference in the frequency of positive peritoneal cytology in those who had hysteroscopy versus those who did not (odds ratio (OR) = 2.6, 95% confidence interval (CI) = 1.02-6.63, P = 0.05). Even after stratifying patients into a low-risk group (OR = 2.12, 95% CI = 0.13-35.9, P = 0.6) and a high-risk group (OR = 3.46, 95% CI = 1.3-9.12, P = 0.01) the difference in the high-risk group was statistically significant. CONCLUSION: Hysteroscopy seems to affect the prevalence of positive peritoneal cytology, especially in those patients with high-risk cell types. Its use in patients with suspicion of endometrial cancer should be reconsidered.     

术前血清CRP测定对评估卵巢上皮癌预后的价值

目的:探讨血清C反应蛋白(C-reactive protein,CRP)与上皮性卵巢癌(epithelial ovarian cancer,EOC)临床病理参数、CA125的相关性及评估EOC预后的价值。方法:测定61例EOC患者术前血清CRP及CA125,分析CRP与临床病理参数及CA125的相关性。结果:术前EOC患者血清CRP的中位数为13.06mg/L,CRP阳性者38例(38/61),明显高于对照组(P<0.001)。术前血清CRP水平与EOC的FIGO分期、淋巴结转移、腹水形成关系密切。FIGOⅢ~Ⅳ期、淋巴结转移阳性、腹水形成者CRP中位数显著增高。多因素Logistic回归分析也提示肿瘤FIGO分期、腹水形成和淋巴结转移与CRP阳性表达相关(P<0.05)。研究还表明,CRP水平与手术方式满意度及残余灶大小关系非常密切,CRP值越高,预示手术满意度越差、残余灶越大;血清CRP、CA125的秩和相关分析显示CRP与CA125之间存在正相关(P=0.000)。结论:术前血清CRP可作为判断EOC预后的有价值指标。     

影响复发上皮性卵巢癌化疗疗效的临床病理因素分析

目的:分析影响铂类敏感型及耐药型复发上皮性卵巢癌(EOC)患者预后的相关临床病理因素。方法:回顾分析1985年1月至2011年11月广西医科大学附属肿瘤医院收治的复发EOC患者83例,其中铂类敏感型56例,耐药型27例。采用Kaplan-meier生存率曲线、Log-rank test检验和Cox模型多因素回归分析法分析影响复发EOC患者预后的相关因素。结果:(1)铂类敏感型复发EOC患者的中位无进展生存期(PFS)为11个月(95%CI 9.105～12.895),中位总生存期(OS)为16个月(95%CI 13.144～18.856);铂类耐药型复发EOC患者的中位PFS为8个月(95%CI 4.219～11.781),中位OS为10个月(95%CI 3.824～16.176)。(2)复发后伴有腹水、复发后化疗方案、化疗疗程、化疗效果是影响敏感型复发EOC患者的重要预后因素(P<0.05);无复发生存时间(RFS)、复发后伴有腹水、复发部位、化疗效果是影响耐药型复发EOC患者的重要预后因素(P<0.05)。(3)复发后化疗疗程数、复发后伴有腹水、化疗疗效是影响敏感型复发EOC患者预后的独立危险因素,而复发部位是影响耐药型复发EOC患者预后的独立危险因素。结论:铂类敏感型患者复发后宜选择与一线类似的铂类联合方案化疗,并尽可能化疗至6疗程。复发病灶位于盆腹腔是影响耐药型患者预后的独立危险因素,应积极治疗。     

Living cytology in the diagnosis of malignant ovarian tumor

Atypical mesothelial cells are sometimes hard to differentiate from cancer cells in the cytology of ascitic or peritoneal washing fluid. The morphological characteristics of the cells, with or without the application of special stains, have mainly been used in differential diagnosis. In the present study, the living cytology described by Monif et al. is applied to the ascites of ovarian cancer patients. 13 cases of ovarian cancer with ascitic fluid were investigated. When 20-30ml ascitic fluid is cultured for a short term, the mesothelial cells transform to fibroblastic cells, and cancer cells form the special islets of cells. This phenomenon is judged as "Positive". The morphology of the ascitic smear and tissue culture of the tumor were also studied for comparison. Living cytology gave the same results as ascitic smear, and made it easier to differentiate mesothelial cells from cancer cells. Cancer cells in living cytology were similar to cells in tissue culture microscopically. In conclusion, living cytology seems useful especially when it is felt difficult to make a diagnosis of cancer cells on the basis of the contamination of active mesothelial cells.     

The usefulness of urinary cytology testing in the evaluation of irritative voiding symptoms

OBJECTIVE: The purpose of this study was to assess the clinical usefulness of urinary cytology testing for the evaluation of urothelial cancer in women with irritative voiding symptoms who were examined at a urogynecology service. STUDY DESIGN: Urinary cytology studies results that were obtained from January 1, 2000, to December 31, 2002, were cross-matched with the Rhode Island Department of Health Cancer Registry to identify those women who were diagnosed with urinary tract malignancies. The prevalence of urothelial cancer was determined, and the sensitivity, specificity, and positive and negative predictive values of urinary cytologic testing were calculated for 2 common classification strategies: (1) consideration of atypical cytologic test results to be normal and (2) consideration of atypical cytologic test results to be abnormal. RESULTS: Among 1516 cross-matched cytologic test results from 1324 patients, 5 urothelial cancers were identified. Two of the 5 malignancies were associated with positive cytology results. The prevalence of urothelial cancer was 0.38% (95% CI, 0.1%, 0.9%). When atypical cytology studies were classified as normal, the sensitivity of urinary cytology was 40% (95% CI, 7.2%, 83.0%); the specificity was 99.9% (95% CI, 99.5%, 100%); the positive predictive value was 66.7% (95% CI, 12.5%, 98.2%), and negative predictive value was 99.8% (95% CI, 99.2%, 100%). In contrast, when atypical cytology results were classified as abnormal, the sensitivity and negative predictive value remained the same, but the specificity declined to 93.6% (95% CI, 92.1%, 94.8%), and the positive predictive value decreased to 2.3% (95% CI, 0.4%, 8.8%). CONCLUSION: The low prevalence of urothelial cancers and low sensitivity of urinary cytology studies severely limit the usefulness of this test in the evaluation of women with irritative voiding symptoms.     

False-negative peritoneal cytology in metastatic ovarian carcinoma

Seventy-nine laparotomies for disseminated intraperitoneal ovarian carcinoma were reviewed to determine the frequency and possible causes of false-negative peritoneal cytology. Negative peritoneal cytology (defined as any reading other than positive) was found in 16 of 79 cases (20%). False-negative cytology occurred more frequently with peritoneal washings (48%) than with ascites (6%; P less than .001); with second-look surgery (50%) than at primary surgery (12%; P = .004); with peritoneal metastasis less than 0.5 cm (50%) than with metastasis greater than 0.5 cm (16%; P = .02); and with bloody cytology specimens (25%) rather than specimens without blood (0%; P = .06). Volume of peritoneal specimen, architectural grade, cytologic grade, and stage of disease (III versus IV), did not affect the frequency of false-negative cytology. The high prevalence of negative cytology associated with peritoneal washings, small tumor size, and second-look surgery suggests that negative cytology is a result of poor distribution of peritoneal washings and infrequent exfoliation of malignant cells rather than misinterpretation of malignant cells present in cytology specimens.     

Correlation of ascitic fluid cytology with histologic findings before and after treatment of ovarian cancer

One hundred thirteen specimens of ascitic fluid from 97 patients with primary, persistent, or recurrent ovarian cancer were examined cytologically. Advanced stage of disease, involvement of the ovarian surface, a moderate or large volume of fluid, and nonbloody serous ascites were factors that correlated with a high rate of positive findings in ascites in these patients. Other factors influencing the positive rate appeared to be the invasive as opposed to borderline malignant histology of the tumor. Involved external surface and volume of ascites were influencing factors only in advanced cases. Therefore, the most important factor influencing the positive rate of ascites cytology was the proportion of cases in advanced stages to total cases.     

Hormone replacement therapy formulations and risk of epithelial ovarian carcinoma

OBJECTIVE: Hormone replacement therapy (HRT) has been inconsistently linked to ovarian cancer. Estrogen formulations in HRT vary in their effects on estrogen-sensitive target tissues, such as the ovary. The aim of the study is to evaluate the impact of various HRT formulations and their characteristics of use on the risk of epithelial ovarian carcinoma (EOC). METHODS: We assessed the association between the use of HRT and the risk of invasive EOC in women participating in a population-based, case-control study conducted in the Delaware Valley from 1994 to 1998. Cases aged 45 or above at diagnosis (n = 484) were compared to community controls (n = 926) frequency matched by age and area of residence. Information on HRT formulation, timing, and duration were obtained by in-person interview by trained interviewers. HRT formulations were classified as opposed (estrogen + progestin) or unopposed (estrogen alone). They were further categorized according to the estrogen component as either conjugated equine estrogen (CEE), the most common formulation, or non-CEE. Multivariate unconditional logistic regression analyses were used to adjust for age at diagnosis, number of live births, use of oral contraceptives, family history of ovarian carcinoma, and history of tubal ligation. RESULTS: Overall, no association was found between any use of HRT and EOC. Although use of unopposed non-CEE was associated with a significant decrease in risk among hysterectomized women (OR = 0.17, 95% CI = 0.04,0.82), this was not true for women with an intact uterus (OR = 1.14, 95% CI = 0.44,2.98; P for interaction = 0.049). No significant differences in EOC risk were observed for other HRT formulations. CONCLUSIONS: Our results did not suggest any consistent pattern of altered risk for EOC and the overall use of HRT by specific formulations of HRT.     

Uterine fibroids and gynecologic pain symptoms in a population-based study

OBJECTIVE: To determine the association between dyspareunia, dysmenorrhea, and noncyclic pelvic pain and the presence and characteristics of uterine fibroids. DESIGN: Population-based cross-sectional study. SETTING: Desio, Italy. PATIENT(S): Six hundred thirty-five non-care-seeking participants of the Seveso Women's Health Study with an intact uterus who underwent transvaginal ultrasound. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Ultrasound-detected presence of uterine fibroids and fibroid characteristics including volume, number, location, and position. Current dyspareunia, dysmenorrhea, and noncyclic pelvic pain was measured by self-report on a visual analog scale. RESULT(S): Uterine fibroids were detected in 96 women (15%). Women with fibroids were more likely to report moderate or severe dyspareunia (adjusted odds ratio [OR] = 2.8, 95% confidence interval [CI] = 0.9-8.3, statistically significant trend) and moderate or severe noncyclic pelvic pain (adjusted OR = 2.6, 95% CI = 0.9-7.6, statistically significant trend) than women without fibroids. Moderate or severe dysmenorrhea was not associated with the presence of fibroids (adjusted OR = 1.1, 95% CI = 0.5-2.6). Number and total volume of fibroids were not related to pain. CONCLUSION(S): This is the first population-based study of gynecologic pain symptoms and fibroids. Dyspareunia and noncyclic pelvic pain, but not dysmenorrhea, increased in severity with the presence of uterine fibroids. Fibroid-associated pain symptomatology in a non-care-seeking population may be different from that of a clinic population.     

Advanced stage mucinous epithelial ovarian cancer: the Hellenic Cooperative Oncology Group experience

OBJECTIVE: Mucinous epithelial ovarian cancer (mEOC) representing about 10% of all EOC are known to be possibly resistant to platinum-based chemotherapy and bear a poorer prognosis with respect to other subtypes of EOC. This study was undertaken to compare response and survival to platinum-based chemotherapy between patients with advanced stages III and IV mEOC and serous EOC (sEOC). METHODS: A retrospective analysis was performed in 47 patients with advanced stage of mEOC treated with first-line platinum-based chemotherapy in the context of several study protocols of the Hellenic Cooperative Oncology Group (HeCOG) between 6/7/1983 and 25/2/2003. The outcome was compared to that of 94 patients with sEOC treated with the same protocols during the same study period (ratio mucinous: serous 1:2). RESULTS: One hundred forty-one patients (47 stages III and IV mEOC, 94 stages III and IV sEOC) treated with platinum-based chemotherapy were analyzed. The overall response rate for mEOC was 38.5% (complete remission 18%) (95% CI 23.4-55.4%) and 70% (complete remission 47%) (95% CI 58.5-80.3%) for sEOC (P = 0.001). After a median follow-up of 77.8 months, median survival and time to tumor progression (TTP) were not significantly different between the two groups (33.2 months [95% CI 23.3-43.1 months] vs. 38.0 months [95% CI 26.8-49.2 months], P = 0.46, 11.8 months [95% CI 7.2-16.4 months] vs. 20.0 months [95% CI 15.7-24.2 months], P = 0.18, respectively). CONCLUSION: Patients with mEOC have significantly lower response to first-line platinum-based chemotherapy compared to patients with sEOC. This low response to platinum-based chemotherapy was not translated in inferior TTP or survival. Our data indicate that a new strategy for chemotherapy in mEOC should be adopted, one that focuses on new agents without cross-resistance to platinum agents.     

Prevalence of cysts in epithelial ovarian cancer

Objective

Ovarian carcinomas mostly appear as large cystic masses. However, the exact prevalence of cysts in epithelial ovarian cancer (EOC) has never been documented as well as the tumor factors that are related to the presence of cysts. Demonstrating the prevalence of cysts in EOC is essential for research focused on predictive and prognostic biomarkers in ovarian cyst fluid.

Study design

From 233 patients with primary EOC who underwent surgery, pathological data were collected from pathology reports. Univariate and multivariate logistic regression were used to analyze the relationship between the presence of cysts and other tumor characteristics.

Results

Cysts in EOC were present in 83.7% of the patients and were mostly (61%) multilocular. The most common histological subtypes (serous, mucinous, endometrioid, clear cell) contained cysts in more than 85% of the cases. In univariate regression analysis, early FIGO stage, low tumor grade and a large tumor size were significantly associated with the presence of cysts (OR (95% CI) = 5.312 (1.81-15.57), 6.906 (2.31-20.66) and 1.169 (1.08-1.27), respectively). In multivariate regression analysis, apart from tumor size, only tumor grade was independently associated with the presence of cysts (adjusted OR (95% CI) = 4.234 (1.36-13.22)).

Conclusions

The large majority of all EOCs contained cysts. Histological subtype, FIGO stage, tumor necrosis and age were not associated with the presence of cystic EOC. In contrast, tumor grade and tumor size were independently related to the presence of cystic EOC. This means that cystic EOCs represent a subgroup of larger and more well-differentiated tumors. The evident relationship between the presence of cysts and differentiation grade is interesting from a clinical point of view as grading is especially important for the prognosis and treatment of patients with stage I EOC.     

Clinical significance of tumor volume in endometrial cancer: A Japan–Korea cooperative study

Objective

The aim of this study was to elucidate the significance of tumor volume as a risk factor for predicting lymph node metastasis.

Methods

We applied the tumor volume index to the data that were collected for 327 Korean patients with endometrial cancer who underwent preoperative assessment including magnetic resonance imaging (MRI) and subsequent surgery including systematic lymphadenectomy. The volume index, which we previously reported in the literature, was defined as the product of maximum longitudinal diameter along the uterine axis, maximum anteroposterior diameter in a sagittal section image, and maximum horizontal diameter in a horizontal section image according to MRI data, from 425 Japanese women with endometrial cancer. Relationships between lymph node metastasis and results of preoperative examinations including volume index were analyzed by logistic regression analysis.

Results

The prevalence of affected lymph nodes was 14.2%. Multivariate analysis showed that high-grade histology assessed by endometrial biopsy [odds ratio (OR); 2.9, 95% confidence interval (CI): 1.4–6.4], volume index (OR; 2.4, 95% CI: 1.1–5.3), node enlargement assessed by MRI (OR; 4.2, 95% CI: 1.4–13.2), and high serum cancer antigen (CA)125 level (OR; 3.6, 95% CI: 1.6–8.1) were significantly and independently related to lymph node metastasis. When volume index was excluded from the analysis, myoinvasion assessed by MRI was an independent risk factor for lymph node metastasis as well as high-grade histology, node enlargement, and high serum CA125 level.

Conclusion

Volume index is compatible with myometrial invasion as a factor for predicting lymph node metastasis in endometrial cancer.     

Multiple cesarean section morbidity.

OBJECTIVE: To quantify maternal risk associated with multiple cesarean sections (CSs) and determine whether the third CS defines a threshold for increased morbidity. METHODS: From January 1997 to January 2002, the clinical records of 3191 women who were delivered by CS at our referral maternity center were examined for selected indicators of maternal morbidity. The women were assigned to groups based on number of CSs and the frequency of each indicator was determined. A composite score for each indicator among women grouped by number of consecutive CSs was then derived to compare risk between groups and against the third CS. RESULTS: By all indicators studied, morbidity increased with successive CSs before and through the third CS. However, compared with the third, the risk of major morbidity was significantly increased with the fifth, and much worse at the sixth CS for placenta previa (odds ratio [OR]=3.8, 95% confidence interval [CI]=1.9-7.4), placenta accreta (OR=6.1, 95% CI=2.0-18.4) and hysterectomy (OR=5.9, 95% CI=1.5-24.4). But the third and fourth CSs had the same risk of major morbidity for placenta previa (OR=1.4, 95% CI=0.8-2.2), placenta accreta (OR=1.0, 95% CI=0.3-2.9) and hysterectomy (OR=0.3, 95% CI=0.0-2.7). CONCLUSIONS: The third CS does not define a threshold for increased risk to the mother. Instead, overall morbidity rises continually with each successive CS. However, specifically for major morbidity from the triad of placenta previa, placenta accreta and hysterectomy during CS, the fourth CS carries the same risk as the third.     

Survival of women diagnosed with malignant, mixed mullerian tumors of the ovary (OMMMT)

OBJECTIVE: To analyze the survival of women with malignant, mixed mullerian tumors of the ovary (OMMMT) compared to women with epithelial ovarian cancer (EOC). METHODS: Data from the Surveillance, Epidemiology and End Results (SEER) Program on 14025 women diagnosed with primary invasive ovarian cancer between 1988 and 1997 were used for this analysis (382 had OMMMT). Differences in distribution of prognostic variables by histological type were compared using a chi-square test. Multivariable survival models were fit using Cox proportional hazards regression analysis to compare risk of death for OMMMT compared to EOC. Analyses were also performed using cases with OMMMT compared to high-grade EOC only. RESULTS: Women with OMMMT were older at diagnosis and were more likely to have primary surgery compared to women with EOC. The majority of women in either histological group had advanced-stage disease at diagnosis. Women with OMMMT had a significant increased risk of death from any cause whether being compared to all women with EOC (HR = 1.69, 95% CI = 1.50,1.90) or to women with high-grade EOC only (HR = 1.58, 95% CI = 1.40,1.79). Women with advanced-stage OMMMT were at a 60% increased risk of death compared to women with advanced-stage, high-grade EOC, after adjustment for other variables of interest (adjusted HR = 1.60, 95% CI = 1.40,1.84). There was no difference in risk of death for these two groups of women with early-stage disease. CONCLUSION: OMMMT is a rare malignancy compared to EOC and had a significantly worse prognosis compared to EOC.     

Endometriosis-associated epithelial ovarian cancer: Primary synchronous different cellular type on each ovary

ObjectiveEndometriosis-associated epithelial ovarian cancer (EOC) is a specific category of EOC, containing either endometrioid or clear cell carcinoma subtype. The characteristic of endometriosis-associated EOC includes an early stage at the diagnosis, presence of single histology type, and better prognosis. The synchronous two subtypes of endometriosis-associated EOC and presentation of far-advanced stage status at the initial diagnosis is rarely reported.Case reportWe reported a 60-year-old postmenopausal woman with FIGO IA endometriosis-associated endometrioid carcinoma at right ovary and FIGO IVA endometriosis-associated clear cell carcinoma at left ovary, right tube, omentum, lymph node and cytology of pleural effusion and ascites treated with optimal debulking surgery and dose-intensity taxane/platinum based chemotherapy.ConclusionThis case report confirms the long-term concept that clear cell carcinoma has much more aggressive behavior than endometrioid cell carcinoma does, regardless of association of endometriosis or not.     

Evaluating the thresholds of abnormal second trimester multiple marker screening tests associated with intra-uterine growth restriction

Our objective was to evaluate the optimal thresholds for unexplained abnormal multiple marker screening (MMS) results that are associated with intrauterine growth restriction (IUGR). This was a case-control study from our perinatal database. MMS analyte levels (multiples of median [MoM]) of cases with IUGR (birthweight < 5th percentile for gestational age) were compared with a control group without IUGR. Pregnancies with fetal anomalies were excluded. Biochemical markers evaluated include alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3). Using receiver operating characteristic curves, the optimal thresholds of MMS (OTMs) associated with IUGR were determined. We identified 255 (12.3%) cases with IUGR and complete MMS records from the database. These were compared with 1785 controls without IUGR randomly selected from our perinatal database in a 1:7 ratio. The OTMs associated with IUGR were AFP > 2.0 MoM (odds ratio [OR] = 2.3; 95% confidence interval [CI], 1.4 to 3.7), hCG > 2.5 MoM (OR = 1.8; 95% CI, 1.1 to 3.2) and uE3 < 0.9 MoM (OR = 2.7; 95% CI, 2.0 to 3.7). The sensitivity, specificity, and positive and negative predictive values for predicting IUGR in the presence of at least one abnormal MMS were 46, 66, 11, and 90%, respectively. Elevated AFP > 2.0 MoM and hCG > 2.5 MoM were the most specific markers for MMS, with specificity of 94 and 95%, respectively. When all three analytes were abnormal, the specificity for predicting IUGR increased to 99%. Abnormal MMS results are associated with IUGR. As a screening tool for IUGR, the biochemical markers were associated with poor sensitivity. Elevated AFP and hCG, however, were highly specific in predicting IUGR. The provided thresholds could be useful in designing policies regarding women who would benefit most from sonographic screening for IUGR.     

Intrauterine tobacco smoke exposure and hyaline membrane disease amongst triplets.

We assessed the association between prenatal smoking and respiratory distress syndrome (RDS) among triplets using a population-based retrospective cohort of 12,169 triplet live births in the United States between 1995 and 1997. Analysis was conducted using the generalised estimating equation framework to adjust for intra-cluster correlations. A total of 938 cases of RDS were reported comprising 35 among smoking (7.2%) and 903 among non-smoking gravidas (7.7%). The likelihood of RDS was comparable in both smoking categories [adjusted odds ratio (OR) = 0.93; 95% confidence interval (CI) = 0.65-1.32]. The risk for RDS due to smoking diminished with declining birth weight albeit non-significantly: low birth weight (OR = 0.99; 95% CI = 0.40-2.42), very low birth weight (OR = 0.85; 95% CI = 0.39-1.86), and extremely low birth weight (OR = 0.69; 95% CI = 0.30-1.58). In conclusion, among triplet neonates, smoking during pregnancy was not associated with respiratory distress syndrome.     

Peritoneal cytology in malignant mixed müllerian tumors of the uterus

Peritoneal cytologic studies (10 ascitic fluids, 18 peritoneal washings) were performed on 28 patients with malignant mixed müllerian tumors of the uterus. The frequency of recovery of malignant cells from the peritoneal cavity was directly related to stage of disease and depth of myometrial invasion. In stage I, positive peritoneal cytology was of greater prognostic importance than depth of invasion: all patients with negative cytology are alive without evidence of disease; all patients with positive cytology are dead.