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J C Felix

Publications and source records attributed to J C Felix.

At least 37 records · Page 2Linked to original sources

Estrogen-progestin replacement therapy and endometrial cancer.

BACKGROUND: It has been known for more than 20 years that estrogen replacement therapy substantially increases a woman's risk of developing endometrial cancer. To reduce this increased risk, progestins have been added to estrogen replacement therapy for between 5 and 15 days (usually 7 or 10 days) per "month" in a sequential fashion (sequential estrogen-progestin replacement therapy) or with each dose of estrogen replacement therapy (continuous combined replacement therapy). At the present time, however, little is known about the effects of varying the number of days that progestin is used in sequential estrogen-progestin replacement therapy. PURPOSE: We sought to determine the effects of sequential estrogen-progestin replacement therapy and continuous combined replacement therapy on a woman's risk of developing endometrial cancer. METHODS: A population-based, case-control study of 833 case subjects and 791 control subjects was conducted. Women were postmenopausal, white, and aged 50-74 years when first diagnosed with invasive endometrial cancer or were aged 50-74 years at the matching date for control subjects. All subjects were interviewed in person with the aid of a month-by-month calendar. Relative risks were estimated by odds ratios (ORs); ORs were adjusted simultaneously for the different forms of hormone replacement therapy and for the known endometrial cancer risk factors. RESULTS: The adjusted OR was 2.17 (95% confidence interval [CI] = 1.91-2.47) per 5 years of estrogen replacement therapy use (based on 422 users among the case subjects and 262 users among the control subjects). For women who received sequential estrogen-progestin replacement therapy with the progestin given for less than 10 days (effectively 7 days) per month, the adjusted OR was only slightly reduced to 1.87 (95% CI = 1.32-2.65) per 5 years of use (74 case subjects and 47 control subjects). However, when progestin was given for 10 or more days (effectively 10 days), there was essentially no increased risk (adjusted OR = 1.07 per 5 years of use; 95% CI = 0.82-1.41) (79 case subjects and 88 control subjects). Continuous combined replacement therapy was also associated with essentially no increased risk (adjusted OR = 1.07 per 5 years of use; 95% CI = 0.80-1.43) (94 case subjects and 81 control subjects). CONCLUSIONS: The progestin in sequential estrogen-progestin replacement therapy needs to be given for at least 10 days to block effectively any increased risk of endometrial cancer. Continuous combined estrogen-progestin therapy is similarly effective. Neither regimen reduces a woman's underlying risk of endometrial cancer. The sharp distinction between the effects of less than 10 days (effectively 7 days) and 10 or more days (effectively 10 days) of progestin use in sequential estrogen-progestin replacement therapy suggests that the extent of endometrial sloughing may play a critical role in determining endometrial cancer risk.

Aged↗

Telomerase activity in benign and malignant epithelial ovarian tumors.

BACKGROUND: Ovarian epithelial tumors include benign lesions lacking invasive and metastatic abilities (cystadenomas) in addition to malignant lesions (carcinomas). An intermediate category, called tumors of low malignant potential (LMP), is also recognized. The merit of this classification is being challenged because the clinical behavior of LMP tumors appears closer to that of cystadenomas than to that of carcinomas. PURPOSE: To verify our hypothesis that the expression of the enzyme telomerase distinguishes these two categories of ovarian epithelial tumors, we examined and compared such expression in ovarian cystadenomas and carcinomas. By examining the expression of telomerase in LMP tumors, we then sought to determine if these tumors were more closely related to cystadenomas or to carcinomas with regard to telomerase expression. METHODS: We examined a total of 64 consecutive ovarian tumors subdivided into 20 carcinomas, 17 LMP tumors, and 27 cystadenomas. We subsequently discarded three of the 27 cystadenomas because of the presence of admixed normal ovarian stroma in those specimens. Tumor subtyping was done without knowledge of the telomerase results, and telomerase assays were likewise interpreted without knowledge of tumor types. Telomerase activity was determined by use of the TRAP (i.e., telomeric repeat amplification protocol) assay. Differences between the proportions of tumors expressing this enzyme in each subgroup were evaluated by use of Fisher's exact test (two-sided). RESULTS: Telomerase activity was detected in all 20 carcinomas and in all 17 LMP tumors examined. In contrast, it was not detected in 19 of the 24 cystadenomas. These differences between rates of telomerase expression in either carcinomas or LMP tumors and those in cystadenomas were statistically significant (P<.0001). All five of the telomerase-positive cystadenomas belonged to a variant called papillary cystadenomas, whereas none of the telomerase-negative cystadenomas belonged to this variant (P<.0001). CONCLUSIONS AND IMPLICATIONS: The presence of telomerase expression in ovarian LMP tumors supports the merit of continuing to separate these tumors from cystadenomas, in spite of their apparent benign clinical course. The finding of telomerase expression in papillary cystadenomas suggests that such tumors may be mechanistically related to LMP tumors and should perhaps be reclassified as variants of LMP tumors. Lack of telomerase expression in ovarian cystadenomas raises questions about the alleged immortality of these tumors because expression of this enzyme is thought to be essential for continuous growth in adult tumors.

Adult↗

Carboplatin as a radiation sensitizer in locally advanced cervical cancer: a pilot study.

Radiation therapy is the mainstay in treatment of locally advanced cervical carcinoma. Several chemotherapeutic agents have been used as radiation sensitizers in the treatment of cervical cancer in an effort to improve local response and survival. A prospective study was designed to evaluate carboplatin as a radiosensitizer in advanced cervical cancer. Standard radiotherapy techniques were used to treat patients with Stage IIA-IIIB cervical cancer. Intravenous carboplatin was administered twice weekly concurrent with external beam radiation. Of 22 evaluable patients, there were 19 complete responders of whom 15 remain alive: 11 patients were alive and disease free at last visit for a median duration of 15 months follow-up (range, 4-43 months) and 4 patients remain alive with disease for a median duration of 17 months (range, 3-55 months). Seven have died, one of whom was without evidence of disease. There were no treatment-related deaths and no grade 4 toxicity. The most significant adverse effect was hematologic resulting in four patients with grade 3 neutropenia or anemia. There were no fistulae or late gastrointestinal or genitourinary complications. This pilot study suggests that carboplatin administered with standard radiation is safe, well-tolerated, and thus may be useful as a radiation sensitizer in the treatment of locally advanced cervical cancer.

Adult↗

Establishment of long-term in vitro cultures of human ovarian cystadenomas and LMP tumors and examination of their spectrum of expression of matrix-degrading proteinases.

OBJECTIVES: To obtain long-term cultures of ovarian cystadenomas and ovarian tumors of low malignant potential (LMP) displaying gene expression patterns similar to those found in vivo and test the hypothesis that such cultures would express different levels of matrix-degrading proteinases than cultured ovarian carcinomas. METHODS: Transfection with an adenoviral expression vector for simian virus 40 (SV40) large T antigen was used to establish long-term cultures of the above tumors. Levels of expression of various genes were evaluated using molecular biological and immunohistochemical approaches. Zymography and reverse zymography were used to examine the activity of various metalloproteinases and plasminogen activators (PA). Two-sided P values for differences in plasminogen activator expression between different cell types were evaluated by Fisher's exact test. RESULTS: Long-term cultures derived from cystadenomas and LMP tumors were obtained which formed colonies on semisolid supports, but were not tumorigenic in nude mice. The cultured cells expressed keratin, estrogen receptor, gonadotropin receptors, BRCA1, and originated from monoclonal populations. There was no apparent association between the malignant phenotype and the expression of either matrix metalloproteinases or tissue inhibitors of metalloproteinases. However, a correlation was seen between this phenotype and expression of urokinase (uPA) and tissue type (tPA) plasminogen activators (P = 0.08 and 0.02 respectively). CONCLUSIONS: The above cell strains provide a useful model for investigating various aspects of the biology of benign ovarian tumors, including their response to steroid and gonadotropin hormones, and the role of specific proteinases in the acquisition of invasive and metastatic abilities.

Antigens, Viral, Tumor↗

Endometrial glandular proliferation and estrogen receptor content during the normal menstrual cycle.

Hysterectomy specimens from 35 normally cycling premenopausal women were examined to determine the relationship of endometrial glandular proliferation to estrogen receptor content. The cases were divided into follicular phase (n = 20), early luteal phase, days 1-5 post ovulation (n = 5) and mid to late luteal phase (n = 10). Proliferation rates, as determined by MIB-1 expression, were maximal in the endometrial functionalis during the follicular phase (701 cells/1000), decreased by half during the early luteal phase (327 cells/1000), and virtually ceased during the mid to late luteal phase (8 cells/1000) (p < 0.001). Estrogen receptor status, determined immunohistochemically and graded on a scale of 0 to 4+, averaged 3.4+, 2.2+ and 0.5+ during the follicular, early luteal, and mid to late luteal phases, respectively, in the endometrial functionalis (p < 0.001). Proliferation rates in the endometrial basalis paralleled those in the functionalis, but at a lower rate, whereas estrogen receptor expression underwent considerably less cyclical variation. We conclude that estrogen receptor status shows a highly significant correlation with glandular proliferation rates and are predictive of endometrial proliferative changes during the normal menstrual cycle.

Adult↗

Risk of residual invasive disease in women with microinvasive squamous cancer in a conization specimen.

OBJECTIVE: To quantify the risk of residual invasion when cervical conization reveals microinvasive squamous carcinoma and to determine whether any factors affect this risk. METHODS: We reviewed the charts and histopathology slides of 87 women who underwent a conization that contained microinvasive squamous carcinoma, followed by either a repeat conization or hysterectomy. Depth of invasion, number of invasive foci, and status of the internal margin and post-conization endocervical curettage (ECC) were assessed. The findings were correlated with the presence of residual invasion. RESULTS: Significant predictors of residual invasion included status of the internal margin (residual invasion present in 22% of women with an involved margin versus 3% with a negative margin; P < .03) and the combined status of the internal margin and post-conization ECC (residual invasion in 4% of patients if both negative, 13% if one positive, and 33% if both positive; P < .015). Depth of invasion and number of invasive foci in the conization specimen were not significant. The power of this study to detect a 25% difference in the risk of residual invasion was 73% for depth of invasion and 75% for number of invasive foci. CONCLUSION: Women with microinvasive squamous carcinoma in a conization specimen in which both the internal conization margin and post-conization ECC are negative have a low risk of residual invasion and are candidates for follow-up or simple hysterectomy. If either the internal margin or the post-conization ECC contains dysplasia or carcinoma, the risk of residual invasion is high and warrants repeat conization before definitive treatment planning.

Carcinoma, Squamous Cell↗

Alterations in DNA methylation are early, but not initial, events in ovarian tumorigenesis.

We compared global levels of DNA methylation as well as methylation of a specific locus (MyoD1) in ovarian cystadenomas, ovarian tumours of low malignant potential (LMP) and ovarian carcinomas to investigate the association between changes in DNA methylation and ovarian tumour development. As we realized that cystadenomas showed different methylation patterns from both LMP tumours and carcinomas, we verified their monoclonal origin as a means of confirming their true neoplastic nature. High-pressure liquid chromatographic (HPLC) analyses showed that global methylation levels in LMP tumours and carcinomas were 21% and 25% lower than in cystadenomas respectively (P = 0.0001 by one-way variance analysis). Changes in the methylation status of the MyoD1 locus were not seen in any of ten cystadenomas analysed but were present in five of ten LMP tumours and in five of ten carcinomas (P = 0.03). These findings suggest that alterations in DNA methylation are absent (or at least not as extensive) in ovarian cystadenomas, but are present in LMP tumours, the phenotypic features of which are intermediate between those of benign and malignant ovarian tumours. The results also emphasize the merit of distinguishing ovarian LMP tumours from cystadenomas, in spite of their similar clinical characteristics.

Blotting, Southern↗

Potential role of the inactivated X chromosome in ovarian epithelial tumor development.

BACKGROUND: Ovarian epithelial tumors can be divided into subcategories often regarded as different stages of neoplastic transformation. Cystadenomas belong to the least aggressive subgroup and are noninvasive and nonmetastatic. Ovarian tumors of low malignant potential (LMP) are intermediate between cystadenomas and carcinomas and show markedly reduced invasive and metastatic abilities. Invasion and metastasis are the hallmarks of carcinomas, which constitute the most aggressive subgroup and can be further subdivided into different grades. PURPOSE: We performed comparative allelotype analyses of ovarian cystadenomas, LMP tumors, and carcinomas, reasoning that such analyses could provide clues about the molecular determinants of their phenotypic differences. Because we realized that allelic losses involving the X chromosome might be associated with LMP tumor development, we determined whether such losses were interstitial and whether they involved the active or the inactive X chromosome. METHODS: Frequencies of loss of heterozygosity (LOH) at specific loci in every chromosomal arm were determined in 16 ovarian cystadenomas, 23 ovarian LMP tumors, 15 low-grade ovarian carcinomas, and 35 high-grade ovarian carcinomas by use of either the polymerase chain reaction (PCR) or Southern blot analyses. We took advantage of the fact that DNA methylation is an important mechanism of X-chromosome inactivation to determine whether losses involving the X chromosome were in the active or the inactive copy. We analyzed the methylation status of retained alleles on the X chromosome by determining whether they could be amplified by PCR after digestion with the methylation-sensitive restriction endonuclease Hpa II. RESULTS: High-grade carcinomas contained frequent(>50%) LOH in four autosomal chromosome arms, i.e., 6q, 13q, 17p, and 17q. Except for 13q, these same chromosomal arms showed frequent LOH in low-grade carcinomas. LOH in autosomal chromosomes was comparatively rare in LMP tumors and was absent in cystadenomas. In contrast, half (eight of 16) of LMP tumors informative for a locus in the proximal portion of chromosome Xq showed LOH at that locus. These losses were the result of interstitial deletions in six of the eight cases and involved the inactive copy of the X chromosome exclusively. Similar losses in the X chromosome were not seen in either cystadenomas or low-grade carcinomas. CONCLUSIONS AND IMPLICATIONS: LOH at multiple loci is associated with the development of ovarian carcinomas but not with the development of cystadenomas and LMP tumors. However, the integrity of a locus in chromosome Xq that possibly escapes X-chromosome inactivation is important for the control of LMP tumor development. The fact that this locus does not appear to be involved in the genesis of low-grade carcinomas suggests that LMP tumors are not precursors of such carcinomas.

Alleles↗

Amplification and overexpression of HER-2/neu (c-erbB2) in endometrial cancers: correlation with overall survival.

Few molecular genetic alterations have been identified in endometrial cancers that are associated with poor clinical outcome. Overexpression of HER-2/neu, transforming growth factor alpha, and p53 proteins have all been associated with poor prognosis in women with endometrial cancer. In this study, the level of HER-2/neu gene amplification and expression was characterized in 92 endometrial cancers. Fluorescence in situ hybridization (FISH) was used to characterize HER-2/neu gene copy number, and immunohistochemistry was used to characterize expression. Forty-seven of the 90 (52%) endometrial cancers were characterized as showing moderate or high immunostaining. HER-2/neu gene amplification was detected in 17 of 81 (21%) cases. Immunohistochemical staining and FISH results were both available for 80 cases. Fourteen of these cases showed both moderate or high immunostaining and gene amplification. Clinical follow-up information was available for 76 women in this study. Women whose endometrial cancer exhibited HER-2/neu gene amplification by FISH had a shorter overall survival than women whose endometrial cancer lacked amplification (P = 0.018). Likewise, tumors with moderate or high HER-2/neu immunostaining were associated with a lower cumulative overall survival than tumors with low immunostaining by log rank analysis (P < 0.0001). Multivariate analysis of survival rates revealed HER-2/neu overexpression to be an independent predictor of overall survival (P = 0.0163). Among those patients with HER-2/neu overexpression, adjuvant chemotherapy or radiation therapy was associated with an improved overall survival (P = 0.039). However, among those women whose tumor lacked overexpression, overall survival was not improved by adjuvant treatment.

Adult↗

X chromosome inactivation and microsatellite instability in early and advanced bilateral ovarian carcinomas.

Ovarian carcinoma can arise synchronously from multiple independent sites and metastasize widely. Therefore, it is frequently unclear whether bilateral tumors represent two independent primaries or one primary and a metastasis. We have used X chromosome inactivation of the androgen receptor gene and microsatellite instability at four chromosomal loci to evaluate the clonal origin of 39 bilateral ovarian carcinomas. An identical monoclonal pattern was found bilaterally in all cases including 10 stage I bilateral ovarian carcinomas. Microsatellite alterations were identified in three cases, and in all three, identical alterations were present in tumor tissue from both ovaries. These results suggest that bilateral ovarian carcinomas evolve as unifocal neoplasias and that metastatic dissemination can occur early in the course of the disease.

Base Sequence↗

The role of endocervical curettage at cervical conization for high-grade dysplasia.

OBJECTIVE: To quantify the risk of invasive cancer above the location where the conization specimen was taken in patients with an endocervical curettage (ECC) positive for dysplasia at conization for high-grade cervical intraepithelial neoplasia (CIN), and to determine if any pathologic features may influence this risk. METHODS: The charts of 104 patients who underwent cervical conization for high-grade dysplasia followed by repeat conization or hysterectomy at Los Angeles County + University of Southern California Women's Hospital between January 1986 and December 1992 were reviewed retrospectively. Patients with invasive cancer or glandular dysplasia on the initial conization were excluded. The ECC performed immediately after conization biopsy (conization ECC) was benign in 63 patients and contained dysplasia in 41. All available conization ECC specimens that contained dysplasia were evaluated for volume of dysplasia and degree of cytologic atypia. Fisher exact test was used for statistical comparison between and within groups. RESULTS: Invasive cancer was not present in any patients in the benign ECC group but was present in nine (22%) patients in the dysplasia group (P < .0001); five of these patients had microinvasion (no more than 3 mm of stromal invasion and no lymph-vascular space involvement) and four had frank invasion. Comparison of patients with involved endocervical margins revealed that none of 37 patients in the benign ECC group versus eight of 27 patients in the dysplasia group had invasive cancer (P < .0005). All patients with invasion were 35 years or older and all patients with frank invasion were 50 years or older. Neither volume nor cytologic grade of dysplasia in the ECC was predictive of invasion in the residual cervix. CONCLUSIONS: An ECC at conization positive for dysplasia is an important predictor of invasion in the residual cervix of patients whose conization reveals high-grade intraepithelial neoplasia and should be routinely performed. Women 50 years or older with both a positive endocervical margin and conization ECC should undergo repeat conization before further therapy. Women under 50 years of age should undergo repeat conization if fertility is not desired; otherwise, close follow-up is necessary to exclude the presence of an invasive lesion in the residual cervix.

Adult↗

Microsatellite instability in sporadic endometrial carcinoma.

BACKGROUND: Recent studies have demonstrated ubiquitous somatic microsatellite mutations in some cancers of the colon, endometrium, stomach, and pancreas. PURPOSE: Our purpose was to characterize the frequency and nature of this replication error (RER) or mutator phenotype in sporadic endometrial carcinoma. METHODS: Formalin-fixed, paraffin-embedded normal and tumor tissues from 45 patients with sporadic endometrial cancer were screened for the RER phenotype at three microsatellite loci. To further characterize when these alterations were acquired relative to clonal expansion, the sizes of the altered microsatellites in different tumor and normal regions were determined using selective UV radiation fractionation. Approximately 150-300 histologically defined cells on stained tissue sections were covered with small ink dots, and UV irradiation was used to destroy the DNA of cells not covered by ink. Undamaged DNA from seven to 25 spots per section were extracted, then analyzed at the Mfd27, Mfd41, and Mfd47 microsatellite loci and also at the c-K-ras gene locus with individual polymerase chain reactions. Radioactively labeled amplified DNAs were analyzed by electrophoresis and autoradiography. Fisher's exact test and the logrank test were used for statistical analysis. RESULTS: The RER positive (RER+) phenotype was detected in nine (20%) of 45 sporadic endometrial carcinomas. The topographic tissue distributions of the altered microsatellites revealed clues to their pathogenesis. The RER+ phenotype was homogeneously present in the primary tumors and their metastases and was absent from adjacent normal and hyperplastic endometrium. The altered microsatellites were predominantly the same sizes throughout five tumors but demonstrated greater intratumor heterogeneity in three tumors. In one case, the primary tumor was stable but its metastasis was unstable. Mutant c-K-ras alleles were significantly more frequent in RER+ (56%) than in RER negative (RER-) (14%) tumors (P = .0165) and appeared to be acquired after the RER+ phenotype in one tumor. There were no significant clinical differences between the RER+ and RER- tumors. CONCLUSIONS AND IMPLICATIONS: The RER+ phenotype is frequently present in sporadic endometrial cancers and is expressed before and during clonal expansion. The underlying mutator mutations are probably heterogeneous, since the RER+ phenotypes were diverse. The absence of altered microsatellites in adjacent normal endometrium demonstrates that the expression of the RER+ phenotype is limited to neoplastic tissue. The bulk of the microsatellite alterations appeared to be acquired prior to clonal expansion, suggesting that expression of the underlying genomic instability contributes to, and is not a consequence of, transformation.

Adult↗

Early mutational activation of the c-Ki-ras oncogene in endometrial carcinoma.

Endometrial carcinoma is theorized to arise from a series of somatic mutations which alter benign endometrium to progressively less differentiated histological lesions. One genetic alteration implicated in the carcinogenesis of endometrial cancer is the mutational activation of the c-Ki-ras oncogene. This study characterizes the frequency and the topographical distribution of activated c-Ki-ras alleles in endometrial carcinoma. Sixty formalin-fixed, paraffin-embedded endometrial cancer specimens were screened for point mutations at codons 12 and 13 of the c-Ki-ras oncogene by polymerase chain reaction and allelic specific oligomer dot-blot hybridization. c-Ki-ras mutations were identified in nine of 60 (15%) tumor specimens. Five cases resulted in G to A transitions, three in G to T transversions, and one in a G to C transversion. These nine mutant tumors were analyzed by selective UV radiation fractionation and polymerase chain reaction for the presence of activated c-Ki-ras alleles in cell populations of various histological phenotype. In eight tumors, c-Ki-ras mutations were uniformly present in the carcinoma cells. One tumor exhibited heterogeneous mutational activation, with mutant c-Ki-ras alleles detected in only grade 2 carcinoma cells but not grade 1 carcinoma cells. c-Ki-ras mutations were present in adjacent hyperplasia with atypia but absent from hyperplasia without atypia. With rare exception, c-Ki-ras activation appears to be an early oncogenic event since it is homogeneously present in premalignant and malignant endometrial tissues.

Adenocarcinoma↗

The significance of positive margins in loop electrosurgical cone biopsies.

OBJECTIVE: To determine the interpretability and significance of the endocervical margins of cervical cone biopsy specimens removed by the loop electrosurgical excision procedure (LEEP). METHODS: Loop electrosurgical cervical conization was performed on 57 women with biopsy-confirmed, high-grade dysplasias in whom the extent of the lesion could not be determined by colposcopic visualization. Internal endocervical margins of the resected specimens were marked with ink by the operating physician and evaluated microscopically by the pathologist. Endocervical curettage (ECC) was done in all instances, and all subjects were followed for 1 year after the procedure. RESULTS: Histologic evaluation of the inked endocervical margins was possible for all 57 resected specimens and was in no instance hindered by thermal artifact. In 19 patients, dysplasia was present in the inked core margin, the ECC, or both. Each patient had re-excisions of the endocervical area; 12 of the 19 (63%) had dysplasia in the specimen. Of 12 cases in which dysplasia was present in both the endocervical margin and the ECC, nine had residual dysplasia. Two of four patients with positive margins but a negative ECC had residual dysplasia, but only one of three patients with a negative endocervical margin and a positive ECC showed residual dysplasia. In the 38 patients with negative inked margins and a negative ECC, there was only one instance of dysplasia demonstrated during the 1-year follow-up period. CONCLUSION: Endocervical margins of cone biopsies removed by LEEP can be accurately assessed pathologically and can help predict the presence of persistent dysplasia.

Adult↗

Analysis of lower genital tract lesions clinically suspicious for condylomata using in situ hybridization and the polymerase chain reaction for the detection of human papillomavirus.

The presence of human papillomavirus was analyzed in 123 biopsy specimens of lower genital tract lesions, clinically considered to be condyloma, using both in situ hybridization and the polymerase chain reaction. Using standard histologic criteria only 22% of the lesions could be diagnosed as condyloma, 17% had features suggestive but not diagnostic of condyloma and 61% lacked the histologic features of condyloma. Human papillomavirus was detected by in situ hybridization in 89% of the lesions with the histologic features of condyloma but in only 3% of the biopsy specimens lacking the histologic features of condyloma. Fifty percent of lesions that had histologic features suggestive, but not diagnostic for, condyloma contained human papillomavirus by in situ hybridization. Using polymerase chain reaction similar results were found. This study underscores the usefulness of human papillomavirus detection methods for analyzing histologically equivocal lesions of the lower genital tract.

Condylomata Acuminata↗