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A vascular necrosis of the femoral head associated with steroid immunosuppression is a cause of significant morbidity in renal transplant recipients. We review the results of 30 total hip replacements in 20 renal transplant recipients with a mean follow-up of 6.3 years. The mean age at the time of surgery was 35 years. The average Hospital for Special Surgery Hip Score was 17 points before operation and 32 points after operation. Fourteen hips were rated excellent and 12 hips rated good. There were four failures--one hip was revised for symptomatic loosening and three prosthesis were removed for infection. Twenty-seven of the hip replacements were subjectively rated as satisfactory by the patient. There was no significant difference in post-operative hip scores between cemented and uncemented prostheses. Total hip replacement in renal transplant recipients in this study has shown good long term result with a revision rate of about 3%. Late infection was a major problem with an incidence of 13%. Prophylactic antibiotics must be used whenever there is a risk of haematogenous seeding from transient bacteremia in these immunosuppressed patients. Use of uncemented prosthesis may make future revision arthroplasty easier.

A retrospective study of the results of operative treatment of 60 long bones secondaries in 46 patients was carried out. The mean period of follow-up was 10 months. The most common primary in this study was carcinoma of the breast (28.2%), followed by carcinoma of the lung (21.7%) and unknown primary (10.9%). Three groups of patients were studied--pathological fracture group, prophylactic fixation group and a mixed group. In the pathological fracture group, 70% of patients achieved good to excellent pain relief and 60.9% was able to walk with or without walking aids. In the prophylactic group, all the patients achieved good to excellent pain relief and 60% were able to ambulate with or without walking aids. In the mixed group, all the patients achieved good to excellent pain relief and 66.6% of the patients were able to walk with aids. The operative mortality in both the pathological fracture group and prophylactic fixation group was 10% and 33.3% in the mixed group. Multiple internal fixation performed at one operative session was associated with high operative mortality (50%).

Risk of malignant transformation in a dysgenetic gonad is high. This is a report of a 23 year-old female who presented with symptoms and signs of ovarian neoplasm which was histologically confirmed as embryonal carcinoma. She had features of Turner's syndrome and was found to have XO chromosomal constitution. Embryonal carcinoma arising in a dysgenetic gonad is uncommon. It is even rarer when it arises in a patient with pure 45 XO. The following is a case report which highlights the role of chemotherapy and surgery in the management. It includes a literature review on the clinical features, genetic variants and malignant transformation in dysgenetic gonad. The role of prophylactic removal of dysgenetic gonad is discussed.

This study was performed to elucidate the presence of human papillomavirus (HPV) infection of the vulva by colposcopy, histology and the polymerase chain reaction (PCR). Colposcopy defined 5 patterns of vulval epithelial lesions inconspicuous to the naked eye. Of these 75 subclinical vulval lesions, HPV infection was diagnosed by histology in 20.0% of minor epithelial changes with faint acetowhitening, 52.2% of conspicuous acetowhite lesions, 63.0% of acetowhite areas with satellite lesions, 84.6% of villous lesions, and 85.7% of villous lesions with surrounding acetowhitening. The corresponding HPV DNA positivity rates by PCR were 60.0%, 73.9%, 70.4%, 84.6% and 100% respectively. The oncogenic HPV type 16 was detected by PCR in 37.3% of the samples. These results provide firm evidence for the prevalent existence of subclinical HPV lesions of the vulva. Some of these infections may not produce significant morphologic changes detectable by colposcopy or histology. Subclinical vulval lesions are common and may constitute a reservoir for repeated cervical HPV infections, as well as a source of contamination of cervical samples for HPV DNA detection by sensitive molecular techniques.

Endometrial sampling with Gynoscann was performed in the outpatient department in 70 women with abnormal vaginal bleeding prior to dilatation and curettage (D&C). Successful endometrial sampling was achieved in 62 (89%) patients; Of the samples obtained 44 (71.0%) were adequate for cytological assessment and 46 (74.2%) for histological assessment, compared to 80% of D&C samples being adequate for histological examination. In those patients in whom outpatient endometrial sampling was adequate, both the cytological and histological diagnosis agreed with the D&C. The outpatient endometrial sampling was well tolerated by the patients since the majority (89%) experienced either no or little pain. Vaginal bleeding following the procedure was minimal in all except 1 patient. Endometrial sampling with Gynoscann may be useful for endometrial assessment prior to commencement of hormonal therapy and hysterectomy. It is a potentially useful screening test for early detection of endometrial cancer in patients at risk.

A rare case of extraskeletal osteogenic sarcoma of the right groin in a 50 year old Chinese lady is being presented. A wide excision of the tumour was done. The differential diagnosis are discussed. This is an extremely rare tumour and is just as malignant and aggressive, if not more so than its counterpart in the bone.

Human papillomaviruses (HPVs) are associated with benign and malignant neoplasms of the cervix. One of the criteria for their etiologic role requires an assessment of whether virtually all or only a small fraction of lesions contain viral genomes. DNA preparations from colposcopically directed punch biopsies of cervical lesions were analyzed by Southern blot hybridization and the polymerase chain reaction (PCR) for the presence of HPV DNA. The biopsy specimens represented different pathologic entities (koilocytosis, condyloma, cervical intraepithelial neoplasia, and invasive carcinoma). In Southern blot hybridization with radioactive probes for HPV 11, 16, 18, 31, and 33, HPV DNA was detected in 74% of the biopsy specimens (42 of 57 cases), with the predominant types being HPV 16 and HPV 18. In contrast, after PCR amplification with primers yielding fragments of characteristic size for HPV 11, 16, and 18, the analysis of the same 57 biopsy specimens revealed that all samples were positive for at least one HPV type. To exclude false-positive PCR results, controls without HPV DNA were interspersed at regular intervals, and results were evaluated only if these controls remained HPV negative. To exclude false-negative results due to failure of the reaction, a target sequence within the c-Ha-ras-1 gene was used as an internal control. All HPV typing results obtained by Southern blot hybridization were in agreement with HPV typing by PCR. The higher number of positive samples in the latter analysis stems from the increased sensitivity of PCR, which was which was effective in identifying as few as 10-100 HPV DNA molecules; in contrast, the sensitivity of Southern blot hybridization was 1 pg, or approximately 10(5) molecules of HPV DNA. The authors conclude that, with sufficiently sensitive diagnostic methods, HPV DNA can be detected in most, if not all, neoplastic cervical lesions.

Chondrosarcoma arising from the spine is a rare malignant tumour, associated with a poor outlook due to inadequate excision in the majority of the cases. We report two cases arising from the cervical and the thoracic spine. Both survived 15 and eight years respectively. This condition carries with it a grave prognosis because of its proximity to the vital structures, making complete extirpation of the tumour frequently difficult if not impossible. Recent developments and progress in adjuvant radiation therapy has improved the prognosis significantly.

Clear cell chondrosarcoma is a form of chondrosarcoma that was first described by Unni in 1976. It is essentially a low-grade chondrosarcoma with many similar clinical, radiological and histological features as the more common chondrosarcomas. However, the distinguishing feature of this variant is in the presence of the characteristic clear cells histologically. We relate two such cases of clear cell chondrosarcoma in Singapore. A short discussion covering the incidence/prevalence of this tumour, its common presenting clinical, radiological and histological features follows. We also review the available world literature, highlight the salient and differentiating aspects of this particular tumour, and touch on its management and eventual prognosis.

In 25 partners of women with genital human papillomavirus (HPV) infection or cervical intraepithelial neoplasia, colposcopic examination revealed the existence of subclinical HPV infection of the male lower genital tract in 22 cases. It manifested either as short papillae tipped with acetowhite changes, or flat acetowhite lesions on the foreskin, glans, periurethral region, scrotum, perineum and/or perianal region. Multiple lesions involving several anogenital areas were common. Some of these abnormalities were small and inconspicuous. Of these 22 cases, 17 had histological evidence of HPV infection. Although Southern blot hybridization detected HPV DNA in only one case, polymerase chain reaction (PCR) analysis revealed HPV DNA in 20 cases. There were 10 cases of HPV 16. Subclinical HPV disease is best identified by colposcopy and confirmed by PCR. In treating HPV disease, colposcopic recognition of subclinical HPV disease forms an essential part of the management plan.

The close epidemiological relationships between specific genital human papillomavirus (HPV) types and neoplasia of the cervix uteri have been extensively documented worldwide, including Singapore. Cervical cancer incidence rates in Singapore show variations between the major ethnic groups. To ascertain the corresponding HPV infection rates among the various races in Singapore, we analysed the cervical smears of 225 women by filter in situ DNA hybridization, and compared the data with a previous similar study. Fourteen (6.2%) individuals were HPV-positive, with HPV 16 and HPV 31 being the commonest types. No significant difference between HPV positivity rates in Chinese (5.0%) and in Malays (6.7%) was found, even though Chinese have a higher cervical cancer incidence than Malays. Furthermore, the cervical HPV carriage rate among women with normal cytology was 5.9%. In the light of reports of high genital HPV prevalence rates detected by DNA amplification, these data support the notion that HPV infection is commonly latent and requires the cooperation of other factors for cervical carcinogenesis.

The occurrence of genital human papillomavirus (HPV) infection was studied prospectively by colposcopy and histology in 43 virginal and 162 sexually active women attending a colposcopy clinic. The study also included 111 husbands of the latter group. By colposcopic criteria, the prevalence of HPV infection was 51.1% in the virginal and 69.1% in the sexually active women. The prevalence was 77.1% among men whose wives had HPV infection compared to 13.3% among men whose wives did not have the infection (p less than 0.01). There was a strong association in genital HPV infection between husbands and wives as expected from a sexually transmissible disease. However, the high prevalence of the infection among the virginal women indicated that transmission of HPV by nonsexual modes was common. Genital HPV infection is ubiquitous and in women is not exclusively a venereal disease.

To evaluate the impact of the routine use of fine needle aspiration cytology (FNAC) on the management of solitary thyroid nodules, 102 consecutive patients were assessed in regard to the proportion of patients being subjected to surgery and the corresponding yield of malignancy. This cohort was compared with a historical control where FNAC was not routinely applied as a diagnostic selection criterion. The percentage of patients operated on had decreased from 95% to 60% (P less than 0.001) without any significant decrease in the field of malignancy: 18.6% vs 17.6% (P = 0.97). The yield of malignancy of patients operated on had increased from 18.4% to 26.2%. Of those not subjected to surgery, 14 patients or 14% of the original cohort experienced spontaneous complete resolution of their nodules after a mean follow-up period of 5.5 months (s.d. = 3.5) (non-resected group). In the retrospective evaluation of diagnostic discriminants to maximize yield of malignancy while minimizing unnecessary surgery for thyroid nodules, the use of combined parameters of clinical suspicion, positive FNAC and age greater than or equal to 50 years detected 100% of malignancies with only 50% of patients requiring surgery. This was superior to other modalities including clinical parameters and expensive investigations of radionuclide scans and ultrasonography. In conclusion, the use of FNAC in the evaluation of solitary thyroid nodules has resulted in a decreased proportion of patients requiring surgery and cost saving while maintaining the yield of malignancy.

We present the results of a clinicopathologic study of 109 patients with endometrial stromal sarcoma and eight patients with endometrial stromal nodule. Of the 109 patients with endometrial stromal sarcoma, follow-up was obtained on 93 (85%). The stage distribution of the patients with stromal sarcoma and the number of patients with follow-up (numerator) compared to the total number of patients in each stage (denominator) are: Stage 1, 73/85; Stage II, 3/6; Stage III, 11/11; Stage IV, 6/7. Stage II patients are considered separately in the analysis. Thirty-six percent of the Stage I patients experienced one or more relapses. Of these, six (23%) died of disease from 11 to 360 months from diagnosis (median, 79 months). Nine (35%) were alive with disease. Of the eleven Stage III patients, eight had one or more relapses and of these, six died of disease. Of the six Stage IV patients, five had one or more relapses and of these, three died of disease. The outcome differences between Stages I, III, and IV are statistically significant (p less than .01). Microscopic features evaluated included the mitotic index (MI = number of mitoses/10 high-power fields) and cytologic atypia. Forty-five percent of Stage I patients who had both rare mitotic figures and minimal atypia had one or more relapses and of these, two (13%) died of disease at 85 and 360 months, respectively. Thus, neither MI nor cytologic atypia were predictive of tumor recurrence for patients with Stage I tumors.

Infection of the cervix uteri with various types of human papillomaviruses is generally considered a necessary factor in the etiology of cancer of the cervix uteri. In many human populations throughout the world, approximately 90% of cervical carcinomas are found to harbour HPV genomes, as judged by Southern blot hybridization, while only a few percent of the cervical smears of asymptomatic individuals contain viral DNA, as assessed by filter in situ hybridization. To obtain corresponding epidemiological data from Singapore, we analysed two groups of 740 and 130 individuals by filter in situ hybridization, and found 4.1% and 6.9% of them to be HPV positive, with HPV 16 and HPV 31 being the predominant types. In consideration of the limitations of filter in situ hybridization, namely low sensitivity and a tendency to suggest false positives due to contaminants, including blood, we analysed the cervical smears of two further groups of 52 and 50 individuals by the polymerase chain reaction for infection by HPV 16 and HPV 18 respectively. With this test, 61% and 14% of the cervical smears proved to be HPV 16 and HPV 18 DNA positive respectively. We conclude that in Singapore, if not worldwide, the majority of the population the population is infected by genital HPV types, suggesting that factors other than HPV infection are ultimately rate-limiting in cervical carcinogenesis.

The results of 30 patients who sustained traumatic posterior dislocation of the hip treated in both Departments of Orthopaedic Surgery in the Singapore General Hospital from January 1980 to May 1987 were analysed. The most common cause was motorcycle accidents. Young adult males formed the majority of affected cases. 90% of the dislocations were of the Types I and II. Associated injuries were common. The primary treatment was closed reduction under anaesthesia. The subsequent period of traction and non-weight bearing was variable, but it did not seem to affect the final results. Avascular necrosis of the femoral head and secondary osteoarthritis were the major complications. The overall functional results were good.

A case of osteosarcoma in a 14 month old girl is reported. The child presented with a history of difficulty in standing for 2 months and x-rays revealed an osteolytic lesion in the upper third of the femur associated with widening of bone and periosteal reaction. Osteosarcoma was diagnosed by biopsy. Treatment was refused and the child died 13 weeks later. Only one other case of osteosarcoma in a child as young as 14 months has been reported. A review of literature showed 22 cases of osteosarcoma in children aged 5 years or younger.

Cancers of the scalp are uncommon. Owing to their unique site they pose problems in surgical treatment. A retrospective study of all scalp cancers notified to the Singapore Cancer Registry over 17 years has shown that squamous cell carcinoma is the most common cancer followed by basal cell carcinoma. Other cancers are sweat gland carcinoma, angiosarcoma, dermatofibrosarcoma protruberans, liposarcoma, fibrosarcoma and malignant lymphoma. Scalp cancers are more common in Chinese and very rare in Indians. There is no difference in the incidence between the sexes. The surgical treatment and reconstructive techniques employed in 52 patients are described. When localised, scalp cancers are managed like other skin cancers but once they invade bone, they become aggressive and are difficult to eradicate. Wide radical excision provides cure and the skull bone if involved should be removed.

A prospective study was conducted in Singapore in 1985 where 107 women with abnormal cervical smears were studied for cervical neoplasia and its association with the human papillomaviruses (HPV), using HPV 11, 16 and 18 DNA as probes. Cervical biopsies were performed for histology as well as for DNA Southern Blot hybridization studies to detect the presence of HPV 11, 16 or 18 genome. The prevalence of the various types of papillomavirus DNA in cervical tissue samples from cervical carcinoma and dysplasias is presented. HPV types 16 and 18 were found in 5 of 8 (63%) cases of invasive squamous cell carcinoma (SCC), in 12 of 41 (29%) cases of squamous carcinoma-in-situ (CIN 3) and in 3 of 48 (6%) cases of lower grade dysplasia. None of our cases of SCC were associated with unknown HPV types detected using a mixture of HPV 16 or 18 DNA under conditions of low stringency. These unknown HPV types were present in approximately one quarter of our cases of dysplasia of all grades.

We have investigated the frequency of persistence or recurrence of tumor in 35 patients with ovarian serous borderline tumors treated by unilateral cystectomy, bilateral cystectomy, or unilateral cystectomy with contralateral oophorectomy or salpingo-oophorectomy. Nineteen of the patients had stage Ia, ten had stage Ib, four had stage Ic, and two had stage III tumors. Tumor persisted or recurred only in the ovary that had been subjected to cystectomy in two (6%) of the 33 patients with stage I tumors, in both the ipsilateral and contralateral ovary in one patient (3%), and in the contralateral ovary only in one patient (3%). The frequency of ipsilateral persistence or recurrence of tumor per ovary subjected to cystectomy in this group of patients was 8%. Both patients with stage III tumors had persistence or recurrence of their tumors. Involvement of the resection margin of the cystectomy specimen and the removal of more than one cyst from an ovary were almost always associated with persistence or recurrence of tumor. Follow-up of the 35 patients showed that despite the occasional complication of persistence or recurrence of tumor, all were alive without evidence of disease 3-18 years after the initial operation, with an average follow-up of 7.5 and a median follow-up of 6.5 years.

This paper assesses the cost effectiveness of fine needle aspiration cytology (FNAC) as a selection criteria for surgery in solitary thyroid nodules compared to scintigraphy and ultrasonography. 98 patients who had FNAC and histological confirmation, scintigraphy and/or ultrasonography were studied. The use of combined diagnostic discriminants of positive FNAC, clinical suspicion and age above 50 years detected all malignancies and would have resulted in fewer patients being subjected to surgery--51% (FNAC) vs 90% (Scans, U/S). This resulted in cost savings of $800 per patient seen. We conclude therefore that FNAC should be the diagnostic modality of choice and that the routine use of scintigraphy and ultrasonography is not justifiable.

A comparative analysis of new cases seen at the Child Psychiatric Clinic in 1975 and 1985 is made in this study. There was a three and a half fold increase in the number of patients seen from 245 to 893. There was no significant change in sex ratio or ethnic groups. However, in 1985 more younger children (aged less than 6 years) were seen at the Clinic. The waiting time remained short with half the number of cases seen within one week of appointment. The commonest conditions besides Normal Variation were Adjustment Reaction, Mental Retardation, Conduct Disorder and Neurosis. Three-fifths of cases were discharged from follow-up within three months of therapy. Most cases (90%) did not require pharmacological therapy whilst family therapy was prescribed for a fifth of cases seen in 1985.

A rare case of epitheloid sarcoma of the vulva is described. This is a soft-tissue malignancy arising from tenosynovial tissue. The patient presented with a painless lump of the vulva of a month's duration. An excision biopsy was performed followed by a wide local excision after the actual diagnosis was confirmed. Post-operatively, her recovery was uneventful and she was seen in the Cancer clinic at regular intervals. Three years following surgery, she was well with no evidence of any recurrence. The suggested mode of treatment ranged from a wide local excision to radical vulvectomy with groin node dissection.

A patient, with two previous term deliveries, presented with post-partum haemorrhage and spontaneous uterine perforation due to choriocarcinoma, requiring emergency laparotomy. Choriocarcinoma following term pregnancy is a rare form of gestational trophoblastic disease. Such tumour appears to follow a more aggressive course with a more extensive metastatic spread and is less responsive to chemotherapy resulting in a poorer prognosis. Choriocarcinoma presenting as postpartum haemorrhage, and spontaneous tumour perforation with intra-abdominal haemorrhage is even rarer. Early diagnosis is an important factor for the patient's survival. A high index of suspicion is required as the tumour may be overlooked. An aggressive chemotherapeutic regime has improved the overall survival.

A family is described in which three siblings had congenital abnormalities consistent with partial trisomy 9q syndrome. Karyotyping indicated that the mother was a carrier of two separate balanced reciprocal translocations involving three chromosomes (46,XX,t (6;8;9)(6q27;8p23;9q32;9q13] resulting from four breakpoints. The three siblings had inherited the der(8) from their mother and hence were partially trisomic for 9q32----9qter and partially monosomic for 8p23----8pter (46,XX,der(8),t(8;9)(p23;q32)mat). The clinical features of the three cases were comparable to those reported in the literature.

A retrospective review was made of 28 surgically treated tennis elbows in the Department of Orthopaedics Surgery O SGH between Jan 1986 and Aug 1988. Biodata, duration of conservative treatment, postoperative results and length of recuperation were analysed. All except one patient was discharged from follow-up at the time of the study. Females outnumber males 2:1.11 cases (75%) were not associated with sports. 21 patients (24 elbows) were contacted by phone. Of these, 91.7% reported excellent or good results based on the postoperative assessment scale by Nirschl (JBJS Vol 61-A No 6, Sept 1979). Average duration of medical leave taken was 2.2 weeks. Average time before return to normal activities was 6.7 weeks.

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