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The manifestation of a malignant melanoma in the uterus is very rare, more often it is the result of metastasis rather than a primary tumor. A malignant melanoma at this site can originate either from melanocytic elements within the cervical epithelium or from the cervical stroma. We report on two cases of primary malignant melanoma of the uterine cervix and compare them with other cases from the literature.

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OBJECTIVES: Aim of this study was to assess the occurrence of pregnancy-related complications of mother and child during pregnancy, delivery and puerperium in women with CCD prospectively. STUDY DESIGN, POPULATION: This prospective multicenter study included 122 pregnancies in 106 women with CCD (72 with, 34 without previous cardiac surgery). Patient age was 17-44, median 26 years. Cardiac and non-cardiac complications, mode of delivery, abortion, and CCD of the newborn were assessed. RESULTS: Initially all women were in Functional Class I or II. Worsening during pregnancy occurred in 25.5% (n=27), mainly during the second and third trimester. Significant problems due to bleeding, hypertension, rhythm disturbances, endocarditis, liver congestion, increasing cyanosis or death, occurred in 11.3%. Twelve per cent of deliveries were premature. Five women had therapeutic abortion, nine spontaneous abortions, nine preterm births, and one intrauterine death. Seventy-nine per cent (n=85) delivered spontaneously; 21.3% (n=23) had caesarean section. Of the 111 live born children, 5.4% (n=6) had a CCD. CONCLUSIONS: Most women with CCD and a good functional class before pregnancy tolerate pregnancy without major problems. However, pregnancy may induce serious cardiac and obstetric complications. The specific risks require an individualized multidisciplinary patient-management by experienced physicians.

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Androblastomas of Sertoli-Leydig cell tumors of the ovaries are classified into the group of sex cord stromal tumors and represent an extremely rare form of tumor (0.2% of all ovarian tumors) in women. Their malignant potential is lower than that of epithelial ovarian cancer. They cause signs of virilization, although these are not obligatory. In many cases secondary amenorrhea is the only symptom of the disease. This leads to an intensive search for the source of the disorder. Frequently only the elevated production of androgens gives a preoperative clue to the tumor type. The recommendation to include the measurement of androgen levels in the routine diagnosis of secondary amenorrhea must therefore be endorsed. The tumors are usually sonographically identifiable; in differential diagnosis, hyperandrogenemia of other origins (e.g., Cushing's disease, adrenal hyperplasia, pituitary adenoma, other causes of ovarian and adrenal androgen hypersecretion, intersexuality, medically induced androgenization) have to be ruled out. In view of the good prognosis, the therapy of choice consists simply in adnexectomy of the affected side. With regular measurement of serum androgen levels an effective control of the course of the disorder is possible. A conclusive pathological diagnosis is difficult as heterologous tumors and mixed tumors exist and, furthermore, other tumor types are capable of imitating Sertoli-Leydig cell tumors.

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A case of complete karyotype discrepancy between cultured chorionic villi and amniotic in addition to fetal cells is reported. Ring chromosome 18 and monosomy 18 mosaicism was detected after amniocentesis. The pregnancy was terminated in the 23rd gestational week. Cytogenetic analysis of cultured umbilical cord tissue after termination confirmed the finding of ring chromosome 18/monosomy 18 mosaicism. In cultured umbilical blood lymphocytes monosomic cells 45,-18 were not detected and the karyotype was 46,XY,r(18). In contrast, short-term and long-term cultured chorionic villi showed a normal male karyotype of 46,XY. Ultrasonographic examination revealed amniotic band syndrome and scoliosis in the caudal region of the spine.

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Bolus tocolysis has been developed to reduce the dose of fenoterol compared to continuous tocolysis. Whereas the high efficacy of pulsatile application of fenoterol has been shown, the proof of reduced side effects is still lacking. A total of 59 patients with preterm labor were divided in three groups: (1) continuous tocolysis and oral application of magnesium (n=19), (2) continuous tocolysis and parenteral application of magnesium (n=20), (3) pulsatile tocolysis (bolus tocolysis) and oral application of magnesium (n=20). Heart rate, systolic and diastolic blood pressure, serum K+ and serum Mg++ were quantified before tocolysis and after 2, 8 and 24 h. Beta-blockers and water balance were recorded over 24 h. Subjective side effects were quantified using a questionnaire with scales graduated covering palpitations, tremor, diaphoresis, thirst, precardialgia and nausea/vomiting. The analysis of the data revealed significantly fewer side effects concerning heart rate, plasma K+ level and the subjective side effects among patients treated with bolus tocolysis than among those treated with continuous tocolysis. Between the latter two groups, no significant difference was found. Concerning blood pressure and need for beta-blockers, no significant differences were found between the three groups. The results of the present study show that especially the side effects subjectively found to be disagreeable by the patients are reduced by pulsatile tocolysis, whereas other side effects show only slight differences between the study groups.

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To investigate the relevance of intraoperative macroscopic evaluation of adnexal masses a prospective study was conducted from June 1st, 1993 to May 31st, 1994, which included 57 premenopausal and 60 postmenopausal women, who underwent laparotomy because of a cystic adnexal mass. The surgeons were asked to classify the tumor intraoperatively as benign or malignant and to assign to histologic groups. In addition cytology of the cyst fluid and a biopsy from the cystic wall were evaluated. Comparison of these items with the results of permanent section diagnosis revealed the tendency of the surgeons to underestimate adnexal masses depending on patients' age and the complexity of the tumor, despite of the knowledge of preoperative ultrasonographic findings. Sufficient cytolologic examination was possible in only one third of aspirates and only 21% of the examined postmenopausal malignant neoplasms have correctly been diagnosed by cytology. Evaluation of the biopsy specimens demonstrates a marked percentage of false negatives with respect to benign tumors (30% of non-functional benign neoplasms in the premenopause were assessed as functional cysts) as well as malignant neoplasms (only 72% were diagnosed correctly in the postmenopause group). In conclusion intraoperative subjective assessment, cytology and representative biopsies do not necessarily concur with the definitive histological diagnosis.

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OBJECTIVE: The aim of the study was to evaluate prospectively the sonomorphological feature of histologically verified endometriotic cysts. METHODS: Transvaginal sonography was performed in 122 patients. Age distribution of the patients, and size and sonomorphology of the lesions were analyzed. RESULTS: Eighty-one percent of the endometriotic cysts occurred in patients between 31 and 50 years old with a peak of 29% between 31 and 35 years. Most of the cysts (81%) ranged between 30 and 59 mm in diameter. Forty-three percent of the endometriotic cysts were observed as monolocular cysts with internal echoes. More than half of the findings were observed to be multilocular, partially without any internal echos, partially even with solid parts or purely solid. CONCLUSION: The so-called 'typically' monolocular smooth-walled endometriotic cyst with internal echoes was only found in 43% of the cases. However, data from the literature show that one cannot assume even this special entity to represent endometriomas. Regarding all monolocular cysts with homogeneous internal echoes, one has to be aware of a great amount of functional cysts and a non-calculable residual risk of malignancy.

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OBJECTIVE: Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome is characterized by a distinct activation of the coagulation system. A mutation of the gene coding for coagulation Factor V (Factor V Leiden) has been identified as the most frequent risk factor for thrombosis. To identify risk factors for HELLP syndrome, we determined coagulation parameters and the Factor V Leiden mutation in women who previously had developed HELLP syndrome. METHODS: Coagulation parameters (activated protein C resistance, antithrombin, protein C, protein S) were determined in 21 women 6 months to 9 years after they had developed HELLP syndrome in the third trimester. In addition, these women were analyzed for the presence of the Factor V Leiden mutation. RESULTS: Of these analyzed women, 33% (seven of 21) had an activated protein C resistance (activated protein C ratio less than 2.0). Another 38% of the women had subnormal activated protein C ratios (2.0-2.3). Only 57% of the women with an activated protein C resistance were identified as heterozygous carriers of the Factor V Leiden mutation (four of seven). CONCLUSION: Women with HELLP syndrome have a higher incidence of Factor V Leiden mutations. This increased incidence does not, however, account fully for the increased frequency of activated protein C resistance in these patients.

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Vessel density counting has been performed in a variety of tumors and used as predictive parameter for the tumor's malignant behavior (metastasis, five year survival). A number of studies have reported conflicting results on the predictive value of vessel density counts. We have quantitated the number of microvessels in routine pathology specimens of paraffin embedded mammary tumors and related these findings to the histopathological diagnosis. Average vessel density counts of vascular hot spots of malignant and benign mammary tumors were similar (34 +/- 15 vs. 31 +/- 10), though significantly higher as in the adjacent normal mammary tissue (12 +/- 5). Analysis of individual tumors, however, showed that significantly more malignant than benign tumors had vessel density counts beyond a defined cut-off value (50 microvessels/HPF). The results suggest that high counts may indeed serve as an independent prognostic parameter. In contrast, low counts may also be observed in malignant tumors and may, thus, not be used as negative prognostic factor.

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Plasma concentrations of the circulating adhesion molecules ICAM-1 (CD54), VCAM-1 (CD106) were determined in 31 women with pre-eclampsia, 9 women with HELLP syndrome, and 13 women with transient pregnancy induced hypertension (PIH). Data were compared with a control group of 157 healthy pregnant women of the same gestational age. Furthermore, concentrations of circulating E-selectin (CD62E), P-selectin (CD62P), and PECAM-1 (CD31) were determined in a subpopulation of 17 women with pre-eclampsia. Plasma concentrations of circulating ICAM-1, VCAM-1, E-selectin, and PECAM-1 were significantly elevated in women with pre-eclampsia compared to healthy control pregnant women. Circulating ICAM-1 and VCAM-1 levels were also significantly elevated in the pre-eclampsia group compared to women with PIH. Concentrations of circulating P-selectin varied strongly in all experimental groups (SD > 70% of the mean), most likely reflecting various degrees of thrombocyte degranulation in the individual samples. Finally, longitudinal profiles of cICAM-1 and cVCAM-1 concentrations were determined in 123 healthy pregnant women between the 16th and the 42nd week of gestation. This analysis identified cICAM-1 and cVCAM-1 as tightly regulated plasma parameters that varied in a small concentration range. Concentrations of cICAM-1 and cVCAM-1 did not vary during pregnancy and the determined concentrations corresponded to the reported reference levels of nonpregnant individuals.

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It is well known that angiogenesis is a fundamental event in the growth of tumors as well as in physiological conditions. In an ongoing prospective study involving eight women, we investigated the microvasculature within the cervix by the use of 3D Color Power Angio imaging. The ultrasound equipment was used in conjunction with specialized software providing high-resolution '3D-Angiomode'. The system provides the ability to visualize blood flow in small vessels that are undetectable by conventional color Doppler techniques and also to study the architecture and determine the number of blood vessels. Comparison of the vessels in the normal cervix with those in the cervix affected by carcinoma or bacterial or viral infection demonstrated that, in malignant tissue, there is a chaotic network of tortuous vessels traversing the tumor mass, whereas, in benign tissue or tissue that is inflamed as a result of infection, the course of the vessels has a regular structure.

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OBJECTIVE: The aim of the present study was the evaluation of simple reproducible sonomorphological criteria for the preoperative evaluation of ovarian tumors in postmenopausal women by use of transvaginal sonography. STUDY DESIGN: Postmenopausal women (> or =1 year of secondary amenorrhea) with ovarian tumors (n=378; tumors > or =3 cm and <3 cm but with solid parts) were examined in a prospective study by transvaginal sonography prior to surgery between 1987 and 1993. The sonomorphological criteria were correlated with the histological findings of the tumors. RESULTS: Of all ovarian tumors in postmenopausal women, 6.3% were functional cysts (follicular or corpus luteum cysts). Almost all of them were detected within the first 5 years of postmenopause. The other ovarian tumors were diagnosed as retention cysts (17.5%), benign neoplasms (39.4%), and malignant tumors (36.8%). Simple ovarian cysts (monolocular, smooth inner wall) represented sonomorphologically the second most frequent type of ovarian tumors in postmenopausal women (35.7%). Of these tumors, 9.6% were diagnosed as malignant. CONCLUSIONS: Simple reproducible sonomorphological criteria proved to be a useful clinical parameter in the preoperative evaluation of ovarian tumors.

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Elastase is produced and released by polymorphonuclear leukocytes (PNMs) during inflammatory processes. Thus, elastase is assumed to be a sensitive marker of infections similar to the well-established C-reactive protein (CRP). It is deactivated predominantly in tissues by alpha1-proteinase inhibitor which forms stable complexes with the elastase molecule (EAPI) that can be detected for several hours. Premature rupture of membranes is often correlated with an early increase in elastase, occurring earlier than the increase in leukocyte count or CRP. Elastase might be a sensitive marker of beginning amnion infection syndrome after premature rupture of membranes. For the present study, plasma EAPI levels of 335 healthy pregnant women as well as 47 healthy nonpregnant pre- and postmenopausal women were analyzed. No significant differences were found in the latter group or in pregnant women until the beginning of labor. Women at the beginning of labor but without rupture of membranes showed a significant increase in plasma EAPI from 97.7 to 338.3 ng/ml (p < 0.001). With opening of the os uteri to more than 2 cm, elastase concentrations decreased to values comparable to those before the beginning of labor (p < 0.001). The use of elastase as a marker for a rupture of membranes or beginning amnion infection syndrome as suggested by a number of studies might need some restriction. As a consequence, serial monitoring of plasma elastase to detect a persisting increase might give more reliable results. The increase in plasma elastase during beginning of labor may be explained by the role of PMNs in the physiology of delivery. However, serial monitoring to detect a persisting increase in plasma EAPI may be more helpful.

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OBJECTIVE: Fifteen percent of patients who later have hemolysis, elevated liver enzymes, and low platelets syndrome develop initially have nonspecific symptoms. Early diagnosis could ensure adequate obstetric management; however, prognostic biochemical tests are lacking. We hypothesized that elevated hyaluronic acid serum levels might be an early indicator of hemolysis, elevated liver enzymes, and low platelets syndrome because it is known to be a sensitive marker of liver cell function. STUDY DESIGN: Hyaluronic acid in serum was measured in patients with normal pregnancies (n = 109) and in those patients with pregnancies complicated by preeclampsia (n = 14) or hemolysis, elevated liver enzymes, and low platelets syndrome (n = 11). RESULTS: A significant increase in hyaluronic acid serum concentrations was observed in patients with hemolysis, elevated liver enzymes, and low platelets syndrome or with preeclampsia (p < 0.05). The extent of hyaluronic acid serum levels in hemolysis, elevated liver enzymes, and low platelets syndrome correlated with the clinical severity of the individual course of disease as measured by intensive care unit time (r = 0.72; p < 0.02). CONCLUSIONS: Serum levels of hyaluronic acid in preeclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome are significantly elevated and might play an important diagnostic and prognostic role in patients with hemolysis, elevated liver enzymes, and low platelets syndrome.

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Monoclonal antibodies have progressed from the laboratory to the clinic. Although recognised in diagnosis there are still problems as far as their therapeutic use is concerned. This review looks at the history, principles of active specific immunotherapy, clinical experience with monoclonal antibodies in therapy of solid tumours, in particular the development of new bispecific monoclonal antibodies, and trials in ovarian, breast and colorectal cancer. Immunoconjugates, linked with radionuclides and cytotoxic drugs, indicate future developments. Conditions for successful therapy, especially with adjuvants in patients with small tumour residues, are also described.

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BACKGROUND: To improve local response and survival, a prospective study was designed to determine the effects of neoadjuvant chemotherapy in the management of cervical carcinoma stage IIB and IIIB. PATIENTS AND METHODS: Fourteen patients were treated with preoperative neoadjuvant chemotherapy. Three courses of carboplatin were administered in combination with ifosfamide in 11/14 patients, whereas 3 patients received three courses of carboplatin and paclitaxel. RESULTS: After neoadjuvant chemotherapy, there were 8/14 clinical responses while 6/14 patients had no change. In 8 cases, Wertheim's hysterectomy was possible after neoadjuvant chemotherapy. Six of these 8 patients are still alive after a duration of 32 months median follow-up, 2 patients died of metastatic disease. In 6 cases with no change after chemotherapy, Wertheim's hysterectomy was impossible. In this subgroup, the median survival time was 15.5 months, and 4/6 patients died of metastatic disease. CONCLUSIONS: Neoadjuvant chemotherapy with carboplatin/ifosfamide or carboplatin/paclitaxel is safe, well-tolerated, effective and useful to enable Wertheim's hysterectomy.

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In a retrospective study, a total of 120 ovarian cancer patients were paired in terms of staging, grading, patent age, and operative and cytostatic therapy. Half of the patients underwent radioimmunoscintigraphy for diagnostic purposes. From the point of view of possible adjuvant immunological therapy, we investigated to what extent patients with treated ovarian cancer benefit from the application of OC 125 in terms of survival time. In our study we have been able to show that at favorable stages (FIGO II) the patient benefitted more from a radioimmunoscintigraphy than at prognostically unfavorable stages (FIGO IV). Even within FIGO stage III we have been able to show, thanks to the large number of cases, that patients with an NED situation benefitted significantly more form radioimmunoscintigraphy in terms of survival than those with residual tumors. Throughout FIGO stage III, patients with radioimmunoscintigraphy showed significantly superior 5-year survival rates (p < 0.05) than those without radioimmunoscintigraphy. These data would appear to justify prospective studies to establish to what extent ovarian cancer patients benefit from an adjuvant application of OC 125 in terms of the 5-years survival rate and the relapse-free interval.

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OBJECTIVE: To what extent is the cesarean section indication "arrest of labour" due to pathological forms of the pelvis and what is the meaning of the assimilation pelvis in modern obstetrics. PATIENTS: NMR-pelvimetries were performed in 166 post partum women from June 1993 to August 1995. The patients were divided into 4 groups. Group 1: patients who had had cesarean section owing to arrest of labour (n = 56), group 2: patients who had had cesarean section due to breech presentation (n = 20), group 3: patients who had had cesarean section owing to another indication (threatening fetal asphyxia, multiple pregnancy, premature delivery, placental abruption, gestosis, n = 40), group 4: patients who had a spontaneous delivery (control group, n = 50). After analysing the NMR pictures all the pelves were alloted to one of the case studies according to their pelvic form. The diagnosis "assimilation pelvis" was made according to the criteria of Kirchhoff (1949). The four groups were compared and analysed. RESULTS: In group 1 an assimilation pelvis was found in 61%. The obstetrically most unfavourable canal pelvis occurred most frequently, amounting to 29%. In only 9% we found a contracted pelvis. In group 2 the proportion of the assimilation pelvis was even higher, rising to 65%. Only 35% of all pelves had a normal shape. In group 3 we found an assimilation pelvis in 50% of all cases. 66% of all patients with spontaneous delivery had a normal pelvis. An assimilation pelvis was found in 34%. In these cases duration of labour was prolonged by 4 hours on average (mean value: 9.5 hours). CONCLUSIONS: Due to its frequency in our days the assimilation pelvis plays a major obstetrical role. This is true in particular when there is a pathological course of labour. From this results that pelvic parameters other than the conjugata vera will be of diagnostic importance, especially those parameters which are able to characterise the assimilation pelvis with its high promontory, the steepness of the pelvic inlet, the lengthening of the birth canal and the decrease of the hollow of the sacrum. We take the view that the angle of the pelvic inlet, the pelvic inclination and the direct length of the pelvis are of outstanding importance.

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