Squamous cell carcinoma of the vulva in a young woman with Crohn's disease

BACKGROUND

Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract. Because Crohn's disease is transmural it may form fistulas to adjacent structures, including the perineum and vulva.

CASE

A 28-year-old white female with a history of Crohn's disease presented with a non-healing vulvar fistula. Biopsy revealed squamous cell carcinoma.

CONCLUSION

Young women may develop squamous cell carcinoma associated with fistulae of Crohn's disease.

Primary squamous cell carcinoma of the endometrium: a case report

PURPOSE OF INVESTIGATION

Primary squamous cell carcinoma of the endometrium (PSCCE) is an extremely rare entity.

METHODS

We present the clinical and pathological findings of a 90-year-old patient with International Federation of Gynecologists and Obstetricians Stage 1C primary squamous cell carcinoma of the endometrium who was treated with hysterectomy and bilateral salpingooophorectomy.

RESULTS

The patient declined adjuvant therapy and continues on progestin therapy. She was free of disease at a one-year follow-up visit. In addition, the current literature is discussed in this report.

CONCLUSIONS

Since primary squamous cell carcinoma of the endometrium is so infrequent, it is difficult to evaluate the efficacy of adjuvant therapy. Although the prognosis historically has been reported as poor compared to endometrial adenocarcinoma, the prognosis does seem to be dependent on the surgical stage at diagnosis rather than on the adjuvant treatment component.

Limited value of routine iron studies prior to initiation of erythropoietin therapy in patients with ovarian cancer

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Background: Anemia is a common consequence of cancer which significantly impacts patient quality of life. The mainstay of treatment for cancer- and chemotherapy-related anemia is erythropoietin therapy. However, approximately 30% to 50% of patients will not respond to these growth factors. The literature attributes this lack of response to functional iron deficiency, when iron stores are normal but the body cannot meet the increased rate of erythropoiesis. We evaluated the iron status of patients with ovarian malignancies receiving chemotherapy and erythropoietin therapy to establish a baseline for implementation of an intervention service. Methods: After obtaining Institutional Review Board approval, we identified 55 ovarian cancer patients receiving erythropoietin therapy from January to December 2005. We then performed a retrospective chart review for patients who had iron studies available. Results: Thirty-four patients had complete iron studies performed, while an additional 10 had only a ferritin level obtained. The mean hemoglobin for all patients was 9.9g/dl (6.9–13.1) with a mean MCV (mean corpuscular volume) of 92.7fl. Four (12%) patients were iron deficient based on ferritin <100ng/ml and iron saturation <20%. However, these patients had normal MCVs, indicating iron deficiency was not the etiology of their anemia. A few patients were assessed for B12 and folate deficiency, but none were identified. Interestingly, we had 22 patients with elevated ferritin levels (greater than 322ng/ml), with the highest being 2178ng/ml. Conclusions: Our results identified a few patients who were iron deficient, but none were diagnosed with iron deficiency anemia. Therefore, the role of routine iron screening in patients with a normal MCV prior to initiation of erythropoietin therapy is in question. We believe that functional iron deficiency may contribute to anemia in our population. Therefore, we suggest that all patients receive iron supplementation at erythropoietin therapy initiation. We plan to prospectively assess the optimal route of iron administration in ovarian cancer patients in order to improve the response rate to erythropoietic growth factors.

No significant financial relationships to disclose.

Methylation of death-associated protein kinase in ovarian carcinomas

Death-associated protein (DAP) kinase is a serine/threonine kinase that plays an integral role in apoptosis and metastasis. The purpose of our study was to determine the methylation status of DAP kinase in ovarian carcinomas. Thirty-one patients with histologically confirmed epithelial ovarian cancers treated at Roswell Park Cancer Institute, Buffalo, New York, between 1987 and 1999 were studied. Sixty-two samples were examined for DAP kinase methylation status: 1 normal human genomic DNA sample from a healthy individual, 1 transformed normal surface ovarian epithelial cell line (IOSE, from Dr Nancy Auersperg, Vancouver, Canada), 2 ovarian carcinoma cell lines (OVCAR3 and A2780), 1 ovarian serous cystadenoma, and 30 ovarian carcinomas. Additionally, peripheral blood DNA was examined from the patients with the serous cystadenoma and ovarian carcinomas. Methylation-specific polymerase chain reaction was performed using primers designed for the unmethylated and methylated promoter regions. The DAP kinase gene was unmethylated in both the normal human genomic DNA sample and the transformed normal surface epithelial ovarian cell line. The two ovarian cancer cell lines were methylated. In the 30 patients with malignant disease, methylation of DAP kinase was observed in 20 (67%). Peripheral blood DNA was available in 26 (87%) of the 30 patients. Comparison of the paired samples indicated that 14 (54%) were methylated and 12 (46%) were unmethylated. There was no correlation between the DAP kinase methylation status and stage, grade, histology, or survival. Methylation of CpG islands in the promoter region of the DAP kinase gene is common in peripheral blood DNA and tissue samples of patients with ovarian carcinomas. This molecular aberration may represent a potential target for therapeutic intervention.

Is there a CA-125 level that predicts negative second look surgery (SLS) in patients with advanced epithelail ovarian cancer (EOC)?

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Background: The value of second look surgery (SLS) in advanced epithelial ovarian cancer (EOC) has been has been questioned because performing this procedure has not been associated with a clear survival advantage.However, SLS continues to be the most accurate means of documenting the response to chemotherapy, and therfore still used in investigational protocols. The primary purpose of this study was to assess the levels of CA 125 after treatment, that could predict absence of disease at SLS. Methods: Between 1998 and 2003, 98 stage III EOC patients who underwent optimal cytoreductive surgery, completed 6 cycles of platinum/paclitaxel chemotherapy, and were NED (no evidence of disease: normal CA 125, normal physical and radiological examination) were included in this study. SLS was performed at 6–8 weeks from completion of primary therapy. Patients with disease present at SLS were considered to have persistent disease and received second line chemotherapy. Patient demographics, surgical and chemotherapy treatments, and CA 125 levels prior to start and at completion of primary treatment were collected retrospectively. Survival was estimated by the Kaplan-Meier method. Results: Forty seven out of 98 (48%) of optimally debulked patients who were NED at completion of primary therapy underwent SLS. Twenty-five out of 47 patients (53%) had evidence of disease at SLS and 22 out of 47 patients (47%) were NED at SLS. The median disease free survival was 42 months (95% CI 16, 81) in patients with negative SLS compared with 17 months (95% CI 9, 45) in patients who did not undergo SLS (p = 0.03). Estimated 5-year survival in patients with negative SLS was 90% compared to 50% in patients who did not undergo SLS (p = 0.05). CA 125 levels of ≤ 10 after completion of primary therapy was predictive of negative SLS (p < 0.05). Conclusions: SLS evaluation of disease status appears to be a more accurate than standard clinical evaluation in patients who are NED at completion of their primary therapy. Negative SLS also appears to be a predictor of improved disease free and overall survival. Furthermore, CA 125 ≤ 10 is predictive of negative SLS in patients who are NED after completion of primary therapy.

No significant financial relationships to disclose.

Efficacy of a gemcitabine based multiagent chemotherapy regimen for advanced uterine sarcomas

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Background: Advanced stage uterine sarcomas (US) have poor prognosis. Active agents in US are doxorubicin, cisplatin and ifosfamide, with response rates (RR) of 25%, 19%, and 17% respectively. Given the poor response, there remains a need for other drugs. Gemcitabine has shown activity in soft tissue sarcomas. In trials with all subtypes of sarcomas, RR observed with single and multiagent schedules are ranging from 3 to 53%. There is scarce data on the use of gemcitabine in US. Aim of our study was to determine the clinical activity of gemcitabine based regimen in patients with US. Methods: From 2002–2005, data from11 chemotherapy naïve patients diagnosed with advanced stage US was reviewed who were receiving gemcitabine/ifosfomide/platinum (GIP) combination chemotherapy regimen in an adjuvant setting after TAH and surgical staging. Ifosfomide 2gm/m2 and Platinum 20 mg/m2 intravenously on days 1, 2 and 3. Gemcitabine 800 mg/m2 intravenously was administered on day 1 of a 28-day cycle. Results: Eleven pts were treated, all stages III and IV. The median age was 49 years. There were 6 carcinosarcomas, 4 LMS, and 1 ESS. Performance status was 0 (6 pts), 1 (5 pts). Four pts (36%) had undergone prior radiotherapy. The site of measurable disease in 10 pts (91%) was in the pelvis. The median number of GIP cycles received per pt was 6 (range 1–9). There were no treatment-related deaths. Hematologic toxicities of > Grade 3 were seen in 82% of pts and consisted of leukopenia and anemia. 36% of pts had an episode of febrile neutropenia. Neurotoxicty (Grade 3 in 2 pts), nausea (Grade 1/2 in 6 pts), and fatigue (Grade 1/2 in 7 pts) were observed. Three (27%) complete responses were observed, four pts had a partial response (36%), for an overall RR of 63%. Four pts had progression of disease (36%). Of the 7 pts demonstrating a response, 4 had previously been irradiated and 3 had not, such that the RR in those previously irradiated was 4/4 = 100% versus 3/7 = 43% in those not previously irradiated. Conclusions: The combination of GIP is well-tolerated and seems to be active in US, yielding RR higher than seen with single agent chemotherapy agents. Pts that received previous adjuvant radiation demonstrated the best responses to this regimen. A randomized trial is needed to evaluate the true value of this regimen in advanced stage US.

No significant financial relationships to disclose.

Methylation of death-associated protein kinase in ovarian carcinomas

Death-associated protein (DAP) kinase is a serine/threonine kinase that plays an integral role in apoptosis and metastasis. The purpose of our study was to determine the methylation status of DAP kinase in ovarian carcinomas. Thirty-one patients with histologically confirmed epithelial ovarian cancers treated at Roswell Park Cancer Institute, Buffalo, New York, between 1987 and 1999 were studied. Sixty-two samples were examined for DAP kinase methylation status: 1 normal human genomic DNA sample from a healthy individual, 1 transformed normal surface ovarian epithelial cell line (IOSE, from Dr Nancy Auersperg, Vancouver, Canada), 2 ovarian carcinoma cell lines (OVCAR3 and A2780), 1 ovarian serous cystadenoma, and 30 ovarian carcinomas. Additionally, peripheral blood DNA was examined from the patients with the serous cystadenoma and ovarian carcinomas. Methylation-specific polymerase chain reaction was performed using primers designed for the unmethylated and methylated promoter regions. The DAP kinase gene was unmethylated in both the normal human genomic DNA sample and the transformed normal surface epithelial ovarian cell line. The two ovarian cancer cell lines were methylated. In the 30 patients with malignant disease, methylation of DAP kinase was observed in 20 (67%). Peripheral blood DNA was available in 26 (87%) of the 30 patients. Comparison of the paired samples indicated that 14 (54%) were methylated and 12 (46%) were unmethylated. There was no correlation between the DAP kinase methylation status and stage, grade, histology, or survival. Methylation of CpG islands in the promoter region of the DAP kinase gene is common in peripheral blood DNA and tissue samples of patients with ovarian carcinomas. This molecular aberration may represent a potential target for therapeutic intervention.

Primary fallopian tube carcinoma: a retrospective clinicopathologic study

INTRODUCTION

Primary fallopian tube carcinoma is a rare tumor. The aim of this study was to evaluate clinical characteristics and management of fallopian tube malignancies at a large tertiary care cancer institute.

METHODS

A retrospective review of the Tumor Registry was conducted to identify all primary fallopian tube carcinomas between 1980 and 2001. Medical charts were retrospectively reviewed. Primary endpoints were overall survival and disease recurrence.

RESULTS

Thirty-five patients had histology consistent with fallopian tube carcinoma. The median age at diagnosis was 56 years. The most common signs or symptoms were abnormal vaginal bleeding (29%) and abdominal/pelvic mass (26%). The most common histology was adenocarcinoma in 16 (46%) patients. Five patients (14%) were Stage I, seven patients (20%) Stage II, 17 patients (49%) Stage III and six patients (17%) Stage IV. Thirty-two (91%) patients received adjuvant chemotherapy and 77% received platinum-based chemotherapy. Twenty-seven (77%) patients underwent second-look surgery, of which 17 patients (63%) were positive for disease. The 5-year survival rate was 64% for Stage I, 42% for Stage II, 32% for Stage III, and 17% for Stage IV.

CONCLUSIONS

Fallopian tube malignancies are rare and carry a poor prognosis. More extensive research needs to be performed to have definitive etiologic, diagnostic and treatment guidelines.

Pelvic exenterations for gynecological malignancies: twenty-year experience at Roswell Park Cancer Institute

The objective of this study is to review the experience with pelvic exenterations for gynecological malignancies at our cancer institute. Charts of 48 women who underwent a pelvic exenteration between January 1980 and December 1999 were reviewed, and several outcomes were analyzed. Majority of patients had received prior radiation therapy. The median survival was 35 months, and the disease-free survival was 32 months. Mortality from the procedure was 4.2%. Early and late postoperative complication rates were 27% and 75%, respectively. Recurrence rate was 60%. Eight patients received intraoperative radiation. Median survival in this group was 11.3 vs 35 months (P = 0.003). Univariate analysis failed to show an association between type of pelvic exenteration, type of fecal and urinary diversion, outcome, need for reoperation, and recurrence. Contemporary pelvic exenterations are associated with a low mortality and a potential for long-term survival in a subset of patients who historically have been given a poor prognosis. In patients with recurrent gynecological cancer confined centrally to the pelvis, pelvic exenteration still remains the choice of therapy as response to chemotherapy to a centrally recurrent tumor in radiated area continues to be poor. Intraoperative radiation in select few patients needs to be further studied.

Pelvic exenterations for gynecological malignancies: twenty-year experience at Roswell Park Cancer Institute

The objective of this study is to review the experience with pelvic exenterations for gynecological malignancies at our cancer institute. Charts of 48 women who underwent a pelvic exenteration between January 1980 and December 1999 were reviewed, and several outcomes were analyzed. Majority of patients had received prior radiation therapy. The median survival was 35 months, and the disease-free survival was 32 months. Mortality from the procedure was 4.2%. Early and late postoperative complication rates were 27% and 75%, respectively. Recurrence rate was 60%. Eight patients received intraoperative radiation. Median survival in this group was 11.3 vs 35 months (P = 0.003). Univariate analysis failed to show an association between type of pelvic exenteration, type of fecal and urinary diversion, outcome, need for reoperation, and recurrence.

Contemporary pelvic exenterations are associated with a low mortality and a potential for long-term survival in a subset of patients who historically have been given a poor prognosis. In patients with recurrent gynecological cancer confined centrally to the pelvis, pelvic exenteration still remains the choice of therapy as response to chemotherapy to a centrally recurrent tumor in radiated area continues to be poor. Intraoperative radiation in select few patients needs to be further studied.

Tumors of low malignant potential arising in the fallopian tube: case reports

BACKGROUND

There is a paucity of information regarding fallopian tube tumors of low malignant potential (LMP) in the literature.

CASE

We present two cases representing alternative management options of low LMP of the fallopian tube.

CONCLUSION

Although low malignant potential tumors of the ovary are relatively common, there are few reported cases of tumors of LMP originating in the fallopian tube. Treatment has been extrapolated from tumors of LMP of the ovary, and conservative fertility-sparing surgery and complete staging procedure remains controversial. We urge continued reporting of these fallopian tube tumors of LMP to enhance understanding of these rare tumors and to develop a more cohesive treatment plan.

Efficacy of adjuvant CYVADIC chemotherapy in early-stage uterine sarcomas: results of long-term follow-up

Data on adjuvant chemotherapy in early-stage uterine sarcomas are conflicting and most often based on small patient groups with relatively short duration of follow-up. Approximately 60% of patients present with stage I disease with an overall 5-year survival of 30-50% when treated with surgery alone. This study examines the efficacy and results of long-term follow-up of a multiagent chemotherapy regimen of cyclophosphamide, vincristine, doxorubicin, and dacarbazine (CYVADIC) as adjuvant treatment for patients with stage I uterine sarcoma. Between 1982 and 1999, 24 evaluable patients with completely staged uterine sarcomas received adjuvant multiagent chemotherapy with vincristine sulfate (1mg /m(2)) on days 1 and 4, doxorubicin (40 mg /m(2)) and cyclophosphamide (400 mg /m(2)) on day 2, and dacarbazine (200 mg /m(2)) on days 1 through 4 for a total of nine monthly cycles or until recurrence of disease was documented. Survival distributions were calculated by the Kaplan-Meier method, and statistical significance was determined with the log-rank test. Factors significant on univariate analysis were analyzed in a multivariate fashion using Cox proportional hazards model. The histologic distribution of patients was 46% leiomyosarcoma, 33% mixed mullerian tumors, 13% stromal sarcomas, 4% adenosarcomas, and 4% hemangiosarcoma. The patients received 206 of a planned 216 cycles of chemotherapy. The median follow-up of the patient population was 93 months (range 11-213 months). Eight patients (33%) developed recurrent disease. The median time to recurrence was 19 months (range 7-184 months). The estimated survival for the entire group was 88, 75, and 69% at 2, 5, and 15 years, respectively. Factors that did not affect survival included age, histology, and tumor grade. Four patients required dose reductions secondary to grade 2-3 toxicities (hematologic). Grade 1 neurotoxicity was observed in six patients (25%) and grade 2 neurotoxicity in one patient (4%). Adjuvant CYVADIC chemotherapy appears to be safe and well tolerated in patients with stage I uterine sarcomas. Our data provide information on the longest duration of follow-up ever reported and suggests that CYVADIC may have a potential role in the adjuvant treatment of early-stage uterine sarcoma.