CORRESPONDENCE

Supplementary women

pyridoxine using

oral

given

to

Microinvasive

contraceptives

the Editors: It is stated in error in Dr. Larsson-Cohn’s’ article, “Oral contraceptives and vitamins: A review,” that “Baumblatt and Winston found that large doses of tryptophan had a beneficial effect on depressive patients receiving oral contraceptives.” It was, of course, pyridoxine that was given,’ based on the hypothesis that pyridoxine deficiency induced by oral contraceptive use might be inhibiting the synthesis of biogenic amines in the central nervous system, thus causing depression.” It would be unwise to give large doses of tryptophan to women suspected of being pyridoxine deficient, because of the danger of accumulation of possibly carcinogeni@ and diabetogenic” metabolites. Moreover, excess kynurenine pathway metabolites may result in a further lowering of brain serotonin, thus aggravating the depression.” Of course, all of this can be prevented by giving supplementary pyridoxine together with the tryptophan. However, once the pyridoxine deficiency is corrected, adequate amine synthesis can usually be anticipated from normal dietary tryptophan, without the need for any additional amino acid. F. Winston,

M.B.

REFERENCES

to Dr.

the

vulva

53719 Reply

1. Larsson-Cohn, U.: AM. J. OBSTET. GYNECOL. 121: 84, 1974. 2. Baumblatt, M. J., and Winston, F.: Lancet 1: 833, 1970. 3. Winston, F.: Am. J. Psychiatry 130: 1217, 1973. 4. Bryan, G. T.: Am. J. Clin. Nutr. 24: 841, 1971. 5. Kotake, Y., and Murakami, E.: Am. J. Clin. Nutr. 24: 826, 1971. 6. Green, A. R., and Curzon, G.: Biochem. Pharmacol. 19: 2061, 1970. Reply

of

the Editors: This concerns a brief communication entitled, *’ ‘Microinvasive’ epidermoid carcinoma of the vulva with an unexpected natural history,” by Drs. Calvin Y. Nakao, James F. Nolan, Philip J, DiSaia, and Robert Futuran, published in the December 15, 197-l, issue of the JOURNAL, p. 1122. The growth described and pictured microscopically was treated by “radical vulvectomy” without inguinal lymphadenectomy. Metastases later occurred in the inguinal nodes on the oppositr side of the small invasive lesion, which eventually resulted in the patient’s death. My concern is with the interpretation of the microscopic pictures as showing “microinvasion.” The lesion shown is certainly not my idea of microinvasion, and I believe that most, if not all, pathologists would agree with me that the growth depicted is small indeed but represents a diffuse infiltrating growth. If the sections showed a spur or two of microscopically unquestionable cancer extending even 5 mm. beneath the general level of the superficial epithelium, but retaining a connection with it, in my opinion that would comprise microinvasion. What do others think? Daniel G. Morton, M.D. 10308 Ashton Ave. Los Angeles, California 90024

To

6102 Odana Road Madison, Wisconsin

carcinoma

To

Winston

To

the Editors: I appreciate very much Dr. Winston’s discovery of my “lapsus.” I wrote “tryptophan” and meant, of course, “pyridoxine.” It is always heartening to an author to realize that his efforts are scrutinized in detail.

Department of Obstetrics University Hospital 58185 Linkiping, Sweden

and

Ulf Larsson-Cohn, Gynecology

to

Dr.

Morton

To the Editors: We could not agree with Dr. Morton’s comments more fully. Just as “microinvasive” carcinoma of the cervix has undergone an evolution in definition from a strict depth of invasion terminology to a morphologic description, we feel that the same principle should be applied to early invasive cancer of the vulva. Some recent reports have suggested that small lesions of the vulva may be treated conservatively. The case report under discussion was believed worthy of publication because it underlines the hazards of grouping early cancers into any category on the basis of size rather than histologic aggressiveness. The lesion in our patient was not invasive on gross examination and presented as a vulvar intraepithelial neoplasia. This intraepithelial neoplasia was multifocal and had not been detected by preoperative sampling although several biopsies had been taken. We recognize that the incidence of lymph node metastases in IeGons like the one presented is indeed quite

M.D.

793

Letter: supplementary pyridoxine given to women using oral contraceptives.

This letter is a response to an article describing the efficacy of administering large doses of tryptophan to depressive patients taking oral contrace...
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