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In proxy decision-making for the dying patient, surrogates and health care providers should be aware that there is documentation and gender disparity in clinical medicine and research in court decisions surrounding the right to refuse life-sustaining treatment. Germ cell tumors are typically rapidly growing, unilateral tumors that present at an early stage (stage I). The margin of resection has long been recognized to be a significant prognostic factor also. A normal cell will never commit itself to such a growth program without having been simulated by these external signals. The development of squamous cell carcinoma of the vulva may be similar to the process that occurs on the cervix. Patient identification must be correct, and the request form should include some indication of the suspected pathology. Contrasting with the unfavorable prognosis for mothers with placental metastases, the prognosis for the infant has been excellent, with 53 of the reported cases revealing no evidence of disease in the baby. In addition, changes in the gastrointestinal function may have an impact on drug absorption of some agents. These acute phase proteins may be used Albumin Albumin is the major plasma protein and is synthesized and secreted by the liver. Several studies have suggested that optimal debulking can be performed in many of these patients with beneficial effect. However, prolonged and multiple episodes may represent a pathologic process such as impending small bowel obstruction, colonic obstruction, or pseudomembranous colitis. In a large study by the American Cancer Society, 897 deaths from colon cancer were identified during 7 years of follow-up of 422,373 postmenopausal women. However, the development of symptoms often indicates disease progression, and appropriate laboratory or radiographic studies may lead to an alteration of treatment. Primitive breast tissue is under the gonadal control of fetal androgen production, which causes a suppression of breast growth during the period of gestation when the tissue is under the simultaneous influence of increasing levels of growth-promoting estrogen and progesterone. They identified 13 patients treated with radical hysterectomy and bilateral pelvic lymphadenectomy with the fetus in situ and 8 others treated with cesarean delivery followed by radical hysterectomy and bilateral pelvic lymph node dissection. The physician arranges the beams to maximize dose to the tumor and minimize dose to normal tissues. Several randomized studies have also been conducted studying the role of paclitaxel for maintenance therapy. If the cancer appears to be locally advanced and not widely metastatic, relief of the ureteral obstruction should be attempted by cystoscopy and placement of retrograde ureteral stents. Irradiation of the fetus between 16 and 20 weeks of gestation may lead to a mild degree of microcephaly, mental retardation, and stunting of growth. Cmelak and Kapp reported their experience of 41 patients who failed to respond to platinum-based chemotherapy. Detection of pelvic abnormalities is more frequent in women of reproductive age because these patients have serial examinations as part of periodic screening for cancer. Although gene therapy in its infancy, if the genetic defect is identified, the gene could be replaced. Darlin and colleagues noted that the technique appears to be an accurate method for identifying lymph node metastases in cervical cancer patients with tumors of 2 cm or smaller. If such treatment bias exists, prompt treatment would not be expected to correlate with good results, and treatment after delivery would appear favorable because of a preponderance of favorable patients in that group. The causes include the nephrotic syndrome, protein-losing enteropathies, burns, haemorrhage and catabolic states. Peters and coworkers have described superficially invasive squamous cell carcinoma of the vagina as a lesion that invades less than 2. Only 38 patients agreed to a second-look laparotomy, and 14 (37%) had negative results. Evaluation of a palpable mass is important to determine whether the mass is cancerous even if the mammogram is negative. Bourne and colleagues identified 1601 high-risk patients on the basis of family history. As with other progestogens, the mechanism of its effect on fibrocystic disease is unclear.

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Finally, there is the concern that irradiation of the fetal and maternal gonads may contribute to reproductive difficulties in the future, of both the mother and her offspring. Gamma rays and x-rays can be collectively called photons, and what is of medical importance is the energy and delivery of the photon, not the source. They found that the total dosage of etoposide was decreased in women with nonmetastatic disease treated with adjuvant hysterectomy compared to those who were treated with chemotherapy alone, again roughly equivalent to a single cycle of chemotherapy. Hammer-Jacobsen suggests that 10 cGy received in the first 6 weeks of gestation should be considered a threshold for therapeutic abortion. Important congenital infections including cytomegalovirus, rubella, and toxoplasmosis must be excluded. Despite the high prevalence in the cancer population, depression is often underdiagnosed and consequently undertreated. Urine protein levels exceeding 2 g require treatment interruption and possible dose reduction depending on protocol requirements. The role of continued surveillance for recurrent disease continues to evolve; thus it is important to 328 11. Giuntoli performed a subset analysis within his large series of patients, identifying 31 patients who received adjuvant radiation therapy. This multivariate logistic regression model combines risk factors to estimate the probability of recurrence of breast cancer over time. In the absence of a palpable mass, invasive carcinoma occurs in less than 40% of cases. The chemotherapy regimens used included cyclophosphamide plus cisplatin (n = 5); single-agent cisplatin (n = 4); single-agent carboplatin (n = 3); paclitaxel plus carboplatin (n = 2); and cyclophosphamide, doxorubicin, and cisplatin (n = 2). Of note, there were 6 infants with hypothyroidism (3%), 4 of whom exhibited mental deficiencies. If the cyst is complex and suspicious for malignancy and increases in size, the patient should undergo exploration earlier than 18 weeks. These complex fistulas are often very difficult to repair, and the patients should be in optimal medical condition before surgery is performed. Care should be taken to visualize and palpate all peritoneal surfaces, particularly the underside of the diaphragm, the surface of the liver, the lateral abdominal gutters, and the small and large bowel mesentery. Nasal congestion Mild symptoms; intervention not indicated Moderate symptoms; medical intervention indicated Associated with bloody nasal discharge or epistaxis - - Definition: A disorder characterized by obstruction of the nasal passage resulting from mucosal edema. Patient symptoms may derive from the physical nature of the mass by producing pressure against the bladder or rectum and increasing abdominal distention. The blood supply and oxygenation varies considerably between these two lesions, with the friable lesion better vascularized and oxygenated and therefore more radiosensitive. Because concurrent platinum-based chemoradiation has become the standard of care for locally advanced disease, many recurrent tumors may therefore be platinum resistant. The logical conclusion derived from this hypothesis is that the maximal opportunity for achieving cure exists during the early stage of disease. In a study by Dalziel, 44 women with lichen sclerosus were evaluated for sexual dysfunction. When compared to similar patients who had low-risk disease and were treated with chemotherapy alone, patients receiving primary hysterectomy had shorter duration of chemotherapy and lower total dosage of chemotherapy, roughly equivalent to one cycle of chemotherapy. In addition, parametrial and vaginal involvement are thought to be more common when the cervix is involved. This follow-up includes a comprehensive physical examination every 2 to 4 months for the first 2 years, every 6 months for the next 3 years, and then annually after 5 years. Equally, low or undetectable urinary potassium in this context indicates the opposite. Clinical note the clinical biochemistry laboratory plays only a part in the overall assessment and management of the patient. The parasympathetic fibers come from S2-4 at the pelvic wall as the pelvic splanchnic nerve.

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If the obstruction is mainly contained in one area, this area can be either resected (if secondary cytoreduction is indicated) or bypassed. Before delivery, gold seeds were placed transvaginally to demarcate the tumor edges. Fallopian Tube Cancer the fallopian tube can become secondarily involved by malignancy through direct extension of an ovarian tumor or from an endometrial carcinoma. This rare and highly aggressive malignant neoplasm primarily affects children and young women between the ages of 10 and 40 years. The alpha level is established by those designing the study and becomes the level of statistical significance. Once the surgical procedure commences, the experienced robotic surgeon can efficiently alternate (swap) control of the various robotic ports through a unique clutching system using both hand and foot controls, can operate all instruments in real time, and has direct control of both monopolar and bipolar electrosurgical energy sources. Fourteen of the 16 with residual teratoma and 6 of the 7 with bulky disease remained tumor free after secondary cytoreduction. Note that of the three examples above, only glucose causes significant fluid movement. These women were followed only 1 year, and they were able to convert proliferative endometrium to atrophic endometrium while using continuous estradiol 50 mcg per day via the transdermal route. Of these, 290 (74%) appeared to have no clear inheritance pattern, and there was no increased risk of cancer in the firstdegree relatives. The potassium concentration inside cells (~140 mmol/L) means that cell damage can give rise to marked hyperkalaemia. The other major mechanism is nonsprouting, which occurs when an existing blood vessel enlarges and splits into two separate vessels. A report by Sevin and associates of eight such cases, out of which three patients died, emphasizes the hazards of a less than optimal workup of patients before cryotherapy. These lesions typically behave like they do elsewhere on the body, with local invasion being the rule. Conservative surgery was performed in 56 of the patients (36 stage Ia, 1 stage Ib, and 19 stage Ic). These include the possibility of decreased immunosurveillance, the longer duration of carcinogenic exposure, and an increased susceptibility of aging cells to carcinogenesis. Proteins can act as buffers, and the haemoglobin in the erythrocytes has a high capacity for binding H+. Varying the time of sample centrifugation may also provide evidence, in the form of a progressive steep rise in serum potassium seen with delayed centrifugation. Furthermore, any tyrosine kinase inhibitor may have off-target effects that damage cardiac muscle cells and impair their survival. If a suspect mutation is found in the cancer member, the relatives without cancer can be tested for that specific mutation. Patients suspected of pulmonary embolism should be evaluated initially by chest radiograph electrocardiography, and arterial blood gas assessment. Research also indicates that the erythropoietin receptor is expressed in several cancer cell lines, raising the concern of possible stimulation of tumor cell growth by these drugs. The malignant neoplasm spreads inside the peritoneal cavity, invading mostly the omentum, with minimal or no involvement of the ovary. It can be used to evaluate a focal mass identified on a mammogram or a palpable mass. Unshaded tissue within the dashed outline is first removed and then reconstructed. A thorough history should be taken to evaluate possible causes of vulvar pruritus. The value of ultrasonography in screening for early ovarian carcinoma has received much attention. Gonadoblastoma Gonadoblastoma is a rare ovarian lesion that consists of germ cells that resemble those of dysgerminoma, and gonadal stroma cells that resemble those of a granulosa or Sertoli tumor. In the human fetus, the period of organogenesis usually ends by the 13th week of gestation. Among 24 cases of cisplatin exposure, 5 have been complicated by growth restriction, fetal demise, hearing loss, and ventriculomegaly. Benefits, in turn, are understood only relative to the goals that the patient and physician hope to achieve through medical care.

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The surgical evaluation of most patients with endometrial cancer requires a thorough inspection of the peritoneal cavity, collection of cytologic washings, and pelvic and para-aortic lymphadenectomy in addition to hysterectomy. The use of image-guided percutaneous biopsy has advantages over surgical excision for the diagnosis of breast lesions. Several treatment options are now available for the nonsurgical candidate with bowel obstructions secondary to advanced cancer. Genetic counseling and testing may then be recommended in order to properly counsel the patient, and her family members, about the benefits and risks of prophylactic mastectomy and bilateral salpingooophorectomy. Still other patients have survived complicated combinations of multiple surgical and adjuvant therapies. If there is no tumor tissue available, then a threegeneration family history is the most powerful means of determining if genetic testing will be helpful. A surgical attack for isolated pulmonary recurrence should be considered, especially if the latent period has been longer than 3 years. After taking initial bite (1a), the needle, with double-stranded suture, is pulled through the open loop end (1b). Diagnosis Patients with an abnormal Pap test who do not have a cervix or patients with an abnormal Pap test result and no cervical abnormality visualized should undergo a careful examination of the vaginal epithelium. Chronic myelogenous leukemia in pregnancy, however, can be managed similar to Hodgkin disease, with a justifiable delay in definitive treatment of several weeks if indicated. These are the regions of the respective tumor suppressor genes responsible for each malignant neoplasm. A few examples are excess skin cancers seen in those exposed to x-rays before safety standards were established, lung cancer in pitchblende miners, bone tumors in radium dial painters, and liver tumors in those exposed to Thorotrast contrast. The differential diagnosis should consider acute appendicitis, intussusception, gastroenteritis, chronic constipation, genitourinary problems, and pelvic infection. Of 38 patients, 11 (29%) had node involvement if invasion of the primary lesion was 5 mm or less, compared with 17 of 28 (61%) if invasion was greater than 5 mm. Duplications gene sequences, observed as a loss of part of a banding region or the loss of heterozygosity of a specific genetic allele. Microinvasive Disease the diagnosis of microinvasive carcinoma in pregnancy is typically established with colposcopic directed biopsy, and in a minority of cases in which the colposcopic biopsy cannot exclude microinvasion, a shallow coin biopsy or the cervix or wedge excision of the area under suspicion as outlined earlier is suggested. Treatment was reduced to once-weekly application in 5 women receiving imiquimod because of severe inflammation. Prolonged slow vaginal bleeding from an endometrial cancer or sarcoma may also result in a patient presenting with profound chronic anemia. These findings suggest that all efforts should be made to avoid intraoperative spillage from the ovary and to limit delay until definitive surgery. Examples include diabetes mellitus, where altered intermediary metabolism in the absence of insulin causes a build up of H+ from the ionization of acetoacetic and hydroxybutyric acids, or loss of bicarbonate from the extracellular fluid. The data on which this recommendation has been made were developed in an era before parenteral broad-spectrum antibiotics. TumorGrade In addition to histologic type, pathologists assign a measure of tumor differentiation, known as grade, to endometrial cancers. In any event, if an extensive cancer is found in the cervix, the prognosis is poor because optimal irradiation cannot be given with the cervix and uterus absent. The decision to operate, then, should be based on a clear communication between the surgeon and patient regarding expectations and definitions of "success. Radical Trachelectomy with Lymphadenectomy In recent years, several reports have appeared describing the successful performance of radical trachelectomy during pregnancy. Compared to ovarian cancer patients, those with fallopian tube carcinoma were more likely to present with earlier stage tumors. Adjuvant Therapy As with other uterine sarcomas, adjuvant therapy has been evaluated to reduce recurrences. In addition to increasing venous flow and pulsatile emptying of the calf veins, external pneumatic compression also appears to augment endogenous fibrinolysis, which may result in lysis of very early thrombi before they become clinically significant. Suturing bleeding points in a cervical cancer is rarely successful because the suture will tear through the tumor. The major effects of renal failure all occur because of the loss of functioning nephrons.

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Pelvic ultrasonography, tumor markers, menopausal status, and clinical presentation all contribute to risk stratification for ovarian cancer. In such cases, broad-spectrum antibiotic therapy should be instituted with coverage for gramnegative, gram-positive, and anaerobic organisms. Size limits for removal of unilocular cysts seem to be related to safety of trocar insertion, surgical exposure, and experience of the surgeon. Patients with an earlier stage and complete surgical removal have a better survival than do patients with advanced disease and suboptimal removal. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. Criteria for prior myocardial infarction Any one of the following criteria meets the diagnosis for prior myocardial infarction: n Development of new pathological Q waves* with or without symptoms; n Imaging evidence of a region of viable myocardium that is thinned and fails to contract, in the absence of a non-ischaemic cause; n Pathological findings of a healed or healing myocardial infarction. When ultrasound was used alone, 15 (42%) of 36 patients with moles did not have a definite diagnosis on first examination. In this study, 24 patients had surgery and 12 are alive, all with less than 2 cm of residual disease. There were 226 pregnancies following therapy, and the rates for miscarriage, preterm, or operative delivery were not increased. The stroma is almost always infiltrated with lymphocytes and often contains granulomas similar to those of sarcoid. The cytostatic nature of the targeted agents may also limit their effectiveness as a single-agent therapy. One of its major benefits is that in women taking tamoxifen, there has been a substantial decrease in the incidence of a second cancer in the opposite breast compared with similar women who were taking a placebo. Severe acute abdominal pain is usually the initial symptom, and the condition is considered to be an acute abdominal emergency. Tumor Size Schink and co-workers evaluated tumor size in 91 patients with stage I disease. Pharyngeal hemorrhage Mild symptoms; intervention not indicated Moderate symptoms; medical intervention indicated Transfusion, radiologic, endoscopic, or operative intervention indicated. It rarely occurs from a Brenner tumor in which there has been mucinous transformation of the epithelium. The major research questions center around limiting the toxicity of chemoradiation, continued intravenous systemic therapy, and the triage of patients with locally advanced resectable lesions. Therefore, it may be prudent to preserve the uterus in patients in whom the ovaries must be removed. Meeuwissen and colleagues found 2 cancers in 133 patients in their series, with 1 of 2 (50%) being a fallopian tube malignancy. Quality-of-life evaluation found a better body image and return to normal activities for the patients undergoing laparoscopy. This is achieved only by maintaining a plasma bicarbonate concentration twice that of normal. In addition, approximately one-third of women who develop vaginal cancer have a history of cervical dysplasia or cervical cancer more than 5 years earlier. Improper placement of the tandem and ovoids may result in an excessive dose to the base of the bladder and speaks to the importance of careful placement of intracavitary devices and attention to bladder doses delivered. These survival rates are similar to what is observed in the nonpregnant breast cancer population. There have been four reports of limb malformations following cytarabine administration during the first trimester; among 89 additional cases in which the drug was given during all trimesters (usually in combination with other agents), adverse fetal events included transient cytopenia (5%), intrauterine fetal demise (6%), intrauterine growth restriction (13%), and two neonatal deaths from sepsis and gastroenteritis. Selected spot biopsies in the areas showing atypical colposcopic patterns, under direct colposcopic guidance and in combination with cytologic testing, give the highest possible accuracy in the diagnosis and evaluation of the cervix. As seen in the text, many of these agents may control disease but not eliminate the disease entirely. Unfortunately, over the past 30 years, there has been little improvement in disease-specific mortality from the three major gynecologic malignancies (Table 18-1). Blood the presence of blood in the urine (haematuria) is consistent with various Case history 11 A patient attending an obesity clinic is found to have ketonuria on urinalysis.

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Care should be taken to prevent spillage of the contents of the dermoid cyst because this material can cause a chemical peritonitis. Hodgkin disease before conception, 10 during pregnancy, and 27 following delivery or pregnancy termination. Concerns regarding sublethal fetal effects of maternally administered chemotherapy have been raised. Two of three study pathologists had to agree on one of the aforementioned five diagnoses for a study panel diagnosis to be established. Blood-borne metastases from breast or colon carcinoma or other extrapelvic tumors may also occur. It is not unusual for women with endometrial cancer to have severe symptoms as a result of withdrawal of estrogen at the time of their diagnosis and surgical treatment. The use of indomethacin is not advisable beyond this period because of concerns of premature closure of the patent ductus arteriosus. Women with large, pendulous breasts will have associated stretching of Cooper ligaments and associated breast pain. Neurologic testing documents loss of ankle and knee reflexes and diminished vibratory sensation. This is well recognized, and virtually all treatment protocols for diabetic ketoacidosis take this into account. Kappa coefficient: Kappa indicates how much observers agree beyond the level of agreement that could be expected by chance. Wound complication Incisional separation of 25% of wound, no deeper than superficial fascia Incisional separation >25% of wound; local care indicated Hernia without evidence of strangulation; fascial disruption/dehiscence; primary wound closure or revision by operative intervention indicated Hernia with evidence of strangulation; major reconstruction flap, grafting, resection, or amputation indicated Death Definition: A finding of development of a new problem at the site of an existing wound. Additionally, the physical examination should exclude the presence of lichen planus on the skin, scalp, nail beds, and oral mucosa. These seven cases exceeded the number of cases in the world literature in adolescent girls born before 1945. A third group encodes proteins that control cell division and are under nuclear control. Because leiomyosarcoma arises within the uterine smooth muscle, biopsy of the malignant tissue is difficult and many lesions are found only at final pathology. Cogent objections have been raised regarding these limited operations, especially in patients with carcinoma of the cervix recurrent after irradiation, because of the increased risk of an incomplete resection. The test must be terminated if more than 3 L of urine is passed or there is a fall of >3% in body weight. Values greater than 120 nmol/L or less than 20 nmol/L require urgent treatment; if sustained they are usually incompatible with life. If cytologic testing, biopsies, or colposcopic examination indicates microinvasive carcinoma of the cervix, conization must be performed to fully evaluate the extent of the invasion, which in turn determines appropriate therapy. Again, this complication can be minimized with diuresis during administration of cisplatin. Although most patients adjusted well in their sample of 74 women, those with lower socioeconomic status and those without family support or religious belief suffered more from adjustment disorders. The interpretation of results n Biochemistry results are often reported as concentrations. Portal vein thrombosis - Intervention not indicated Medical intervention indicated Life-threatening consequences; urgent intervention indicated Death Definition: A disorder characterized by the formation of a thrombus (blood clot) in the portal vein. In most cases, nausea and vomiting can be relieved by conservative measures, and intestinal symptoms usually resolve after primary cytoreductive surgery and multiagent cisplatin-based cytotoxic chemotherapy. Although risk in vulvar cancer was not specifically evaluated because of small numbers, all women undergoing pelvic radiation had a higher rate of pelvic fracture than women with pelvic malignancies who did not undergo irradiation, and the majority of fractures (90%) involved the hip. The discovery of gonadoblastoma is made in the course of investigation of these conditions. Individuals can inherit defective genes that alter lipid metabolism, and therefore those people are at risk for development of atherosclerosis and thus have an increased risk of dying of a fatal myocardial infarction or stroke. Alternatively, breast cancer regressions were also achieved by administering large doses of estrogen, androgen, progesterone, and glucocorticoids. In this series, fertility sparing surgery was performed in 41 cases and pregnancy was achieved in 12 of 16 (75%) of women who attempted to conceive, demonstrating that conservative surgery plus chemotherapy resulted in an appreciable number of successful pregnancies after treatment. Lymphocele Asymptomatic; clinical or diagnostic observations only; intervention not indicated Symptomatic; medical intervention indicated Severe symptoms; radiologic, endoscopic, or elective operative intervention indicated - - Definition: A disorder characterized by a cystic lesion containing lymph.

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Because the period of gestation is no longer than 9 months, it is difficult to believe that the sole explanation for the high incidence of advanced disease in pregnancy is related to late diagnosis caused by the engorged breast. Typical symptoms of cystitis are usually present but urine cultures show no significant bacterial growth. Gynecologic oncologists will usually use a total of 4 to 6 ports to obtain adequate exposure and accomplish advanced pelvic procedures. In 2010 Holt summarized the Endocrine Society Guidelines for the management of thyroid dysfunction during pregnancy and postpartum. Kurman reported a 20% incidence of disease in the serially sectioned normal appearing opposite ovary. He noted that cases of familial retinoblastoma were more likely to be bilateral or multifocal. Seizure Brief partial seizure; no loss of consciousness Brief generalized seizure Multiple seizures despite medical intervention Life-threatening; prolonged repetitive seizures Death Definition: A disorder characterized by a sudden, involuntary skeletal muscular contraction of cerebral or brain stem origin. Killackey reported that 17% of laparotomies in gynecology are performed primarily for this indication. The survival of an animal with cancer is inversely related to the number of cancer cells. Testing for a specific mutation is much cheaper for the family than sequencing the whole gene-a few hundred dollars compared to $3500 for the whole gene. The vast majority of analgesics and anesthetics are category C drugs (Table 15-10). In an effort to remove visible tumor deposits and achieve optimal cytoreduction, gynecologic oncologists frequently perform radical surgical procedures beyond those required for standard staging. Two of three limb abnormalities seen following doxorubicin exposure during the first trimester (n = 25) may be confounded by concomitant radiation or cytarabine treatment. Conservative surgery without radiation or adjuvant chemotherapy in stage Ia lesions has resulted in excellent outcomes (Table 12-3). A patient whose serum sodium falls from 145 to 125 mmol/L in 24 hours may be at great risk. The Clark classification, which uses histologic levels, is outlined in Table 8-14. Thus, as the patient begins to take fluids orally, any salt ingested is maximally retained. Class I operations are advocated primarily for in situ and true microinvasive carcinomas of the cervix. Therefore, reirradiation for recurrent disease is usually not a worthwhile consideration. In these patients, neoadjuvant chemotherapy, rather than surgical intervention, may be the best option. In a prospective, randomized trial, Coleman reported significant improvement in laparoscopic proficiency in residents exposed to a laboratorybased skills curriculum. This study included 1 year of maintenance bevacizumab (15 mg/kg every 21 days), which resulted in mild toxicity over a median of 17 maintenance bevacizumab cycles. It may appear confusing that carbonic acid can cause an acidosis, since for each hydrogen ion produced, a bicarbonate molecule is also generated. Early studies were conducted with selective lymphadenopathy or lymph node sampling (only visibly enlarged lymph nodes are selectively removed). The contemporary use of these agents in epithelial ovarian cancer is rare to nonexistent. In such cases, intradermal and lesional injection of steroids has been reported to be effective. Control appears to be mediated by an unknown feedback mechanism, probably resulting from contact phenomena when cells are crowded together. Averette and colleagues reported the largest series of cold knife cervical conization biopsies in pregnancy and noted that 9. Finally, Steed and colleagues reported a 28 year old with antepartum bleeding at 20 weeks of gestation who was found to have a 6-cm diameter anterior vaginal wall squamous cell carcinoma extending to the right lateral fornix. Bevacizumab at the typical doses given for gynecologic malignancies (10-15 mg/kg) has an incidence of hypertension between 18% and 36% compared to an incidence of 3% to 30% in patients treated with low-dose bevacizumab (3-7. A cell carrying such a mutant gene might, in turn, respond to this damage by launching a program of deregulated growth and thus become a cancer cell. Disease more commonly occurs on the labia majora; however, it may appear on the labia minora, clitoris, or perineum.