BACKGROUND Isoforms of the adhesion molecule CD44 are involved in carcinogenesis and the metastatic cascade of tumor cells by increasing the affinity of malignant cells to their extracellular matrix. Preliminary data with respect to the prognostic value of the CD44 isoforms CD44v3 and CD44v6 in patients with vulvar carcinoma showed promising results. The current multicenter study aimed to determine the prognostic value of CD44v3 and CD44v6 in patients with surgically staged vulvar carcinoma. METHODS Expression of CD44v3 and CD44v6 in vulvar carcinoma tissue was assessed by immunohistochemistry. Immunohistochemic staining was performed according to established protocols. Results were correlated to clinical data. RESULTS A positive CD44v3 and CD44v6 staining was detected in 33.3% (33 out of 99) and 39.4% (39 out of 99) of the tumor samples, respectively. Overexpression of CD44v6 was associated with an impaired prognosis with respect to disease‐free survival (P = 0.01) and overall survival (P = 0.04). Multivariate analysis showed that CD44v6 provided prognostic information with respect to disease‐free survival (P = 0.001) and overall survival (P = 0.005) independently of the two established prognosticators, tumor stage and groin lymph node involvement. Overexpression of CD44v3 had no impact on patient survival. CONCLUSIONS The current multicenter study, involving a large series of patients with surgically staged vulvar carcinoma, allowed for multivariate survival analysis and showed that CD44v6 confers prognostic information in addition to that provided by the established clinicopathologic parameters of tumor stage and lymph node status. Cancer 2002;94:125–30. © 2002 American Cancer Society.

A 31-year-old Jehovah's Witness, with a past history of a previous elective Caesarean section for breech presentation, was diagnosed with a major anterior placenta praevia in the current pregnancy. Blood product use was discussed and an advance health directive signed by the patient and consultant. The patient refused blood products, but consented to cell salvage, presurgical acute normovolaemic haemodilution, erythropoietin use and possible early recourse to hysterectomy.The patient was admitted at 27 weeks' gestation following a small bleed from the placenta praevia; steroids were prescribed to promote fetal lung maturity. Over the following weeks, the patient was seen by anaesthetic, haematology and paediatric staff. Erythropoietin therapy was commenced and her iron supplementation increased.From 30 weeks' gestation, the patient had repeated small antepartum haemorrhages. A plan was made to deliver her electively at the end of her 32nd week following preoperative acute normovolaemic haemodilution and intraoperative cell salvage.Five days prior to her scheduled operation, repeated small amounts of vaginal bleeding, associated with persistent uterine tightenings, forced the decision to undertake delivery at that time.Pre-operative acute normovolaemic haemodilution was performed prior to administering a general anaesthetic, giving a preoperative haemoglobin of 104 g/L (from 115 g /L). In view of the poorly formed vascular lower segment, a classical uterine incision was performed. The membranes were not ruptured on entry and the baby was delivered 'en caul' (i.e. with the membranes intact) as a breech. Apgar scores were 5 at 1 min, 8 at 5 min, cord pH was 7.36, and baseline neonatal haemoglobin was 135 g /L.Delivery of the infant en caul allowed the cell saver to be used without concern over amniotic fluid contamination; 400 mL autologous blood was re-infused to the patient via the cell saver. Although the estimated blood loss was 1.7 L, the haemoglobin concentration was 90 g /L on day 1. The woman made an otherwise uneventful recovery; the infant had mild respiratory distress syndrome, but was discharged at 23 days. DiscussionThe key issues in managing patients who refuse blood products are establishing a dialogue with the patient, optimising blood indices early, multidisciplinary input and occasionally intervening earlier to pre-empt disaster. 1 Cell salvage is used in surgery where heavy blood loss is anticipated 2 and involves the rapid collection, washing, and re-infusion of blood lost from the operative field. The procedure is relatively contra-indicated in obstetrics because blood contaminated with liquor could potentially cause an amniotic fluid embolism. Adequacy of the washing process to minimise this risk is difficult to assess. 2 Although 175 successful cases have been reported in the obstetric literature, 3 this is an inadequate number to quantify the risk of amniotic fluid embolism, with an incidence of up to 1:80 000 deliveries.This case describes a novel method to avoid cell saver contamination fro...