Percutaneous transcatheter embolization for control of life-threatening pelvic hemorrhage from gestational trophoblastic disease

Pelvic hemorrhage from gestational trophoblastic disease remains a common and vexing problem. Traditional surgical therapy, including hysterectomy and hypogastric artery ligation, may be technically difficult as well as hazardous to debilitated patients. In contrast, percutaneous transcatheter embolization specifically occludes the vessels that directly contribute to bleeding. Other potential advantages include avoidance of general anesthesia and major surgery, a rapid recovery period, and preservation of fertility. Various embolic materials allow one to tailor the duration of occlusion to the underlying disorder. Reported complications are rare and generally involve aberrant emboli or inadequate collateral circulation leading to ischemic injury. We believe that transcatheter embolization should be considered an alternative to operative intervention for control of pelvic hemorrhage from gestational trophoblastic disease.

"Poor prognosis" metastatic gestational trophoblastic disease: the prognostic significance of the scoring system in predicting chemotherapy failures

Twenty-eight patients with "poor prognosis" metastatic gestational trophoblastic disease were treated during a 17-year period. The primary treatment was combination chemotherapy with methotrexate, actinomycin D, and chlorambucil (MAC). Patients who failed to respond to this regimen were treated secondarily with other combinations. Adjuvant surgery and radiotherapy were used in selected cases. The overall remission rate was 89% (25 of 28): 71% for first-line treatment with MAC (20 of 28) and 62% for second-line treatment (five of eight). The response rate to MAC correlated well with the patient's score (modified World Health Organization [WHO] scoring system--1983). Seventeen patients treated with MAC had scores less than 12, and all of them achieved remission. Of 11 patients having scores of 12 or more, only three achieved remission with MAC (27%). Of the eight who did not, five achieved remission with other combinations (62%) and three died. No patient died because of chemotherapy toxicity. The WHO scoring system is a good index to select high-risk patients who need primary chemotherapy more aggressive than MAC.

Vaginal reconstruction after exenteration with use of gracilis myocutaneous flaps: the University of California, San Francisco experience

At the University of California, San Francisco Medical Center we have performed 18 vaginal reconstructive procedures with gracilis flaps at the time of anterior, posterior, or total pelvic exenteration. We have compared these patients with 13 other patients undergoing exenteration during the same interval who chose not to have vaginal reconstruction. There was no significant difference between the two groups with respect to age, weight, operating time, blood loss, or duration of postoperative hospitalization, but there were significantly fewer serious complications in the patients receiving gracilis flaps. The results of a questionnaire indicated that the perineal cosmetic results are highly acceptable, although residual scarring on the legs is a common source of minor complaint. Sexual adjustment can be complete or nearly complete in surviving patients. Given the major contribution to wound healing, reduced postoperative morbidity, excellent cosmetic results, and the opportunity for complete sexual rehabilitation, we believe the gracilis myocutaneous flap neovagina remains the procedure of choice for most women undergoing major exenterative procedures.

Fine-needle aspiration biopsy in the management of cervical carcinoma following primary therapy

Thirty-five fine-needle aspiration biopsies (FNAB) in 30 patients who had previously received primary therapy for cervical carcinoma are reported. There were 22 positive FNABs, and in 11 cases the positive FNAB definitely changed the patient's planned therapy. There were no complications due to FNAB in these 30 patients. FNAB has an important role in follow-up and management of patients with cervical carcinoma.

Gestational trophoblastic neoplasm of the uterus: MR assessment

Magnetic resonance (MR) imaging characteristics of uterine gestational trophoblastic neoplasia were prospectively studied in nine women (aged 21-58 years). MR imaging was done at the time of initial clinical diagnosis, after each of the first two cycles of chemotherapy, and 6-9 months after initiation of chemotherapy. Sagittal and transverse MR images of the pelvis were generated with a 0.35-T superconducting magnet and the double spin-echo technique with short and long repetition times (TRs). The neoplasm distorted the MR appearance of uterine zonal structures (myometrium, endometrium, and junctional zone) and demonstrated hypervascular masses of heterogeneous signal intensity. Favorable response to chemotherapy was determined by a decrease in serum beta-subunit human chorionic gonadotropin (HCG) concentrations, and was accompanied by MR findings of regression of vascular abnormalities, development of intralesional hemorrhage, and return of normal appearance of uterine zones. The return of uterine zonal anatomy on MR images antedated definitive decrease in uterine volume. All eight patients imaged 6-9 months after initial imaging showed normal uterine volume and zonal anatomy.

Malignant fibrous histiocytoma of the vulva

Primary sarcomas of the vulva are rare neoplasms; malignant fibrous histiocytoma is a sarcoma that usually occurs in the extremities of elderly patients, but it also has been seen in a number of other sites. Presented is the second case report of malignant fibrous histiocytoma arising in the vulva. The diagnosis and management of vulvar sarcomas are reviewed.

Further observations on the sonographic spectrum of gestational trophoblastic disease

Sonograms of 27 patients with gestational trophoblastic disease were evaluated and categorized to newer concepts regarding the pathology and pathogenesis of this disorder. The patients were assigned to the following subgroups: 1) classical or complete mole; 2) partial or incomplete mole; 3) coexistent mole and fetus; 4) hydropic degeneration of the placenta; 5) locally invasive mole; and 6) metastatic trophoblastic disease, including choriocarcinoma. The utility of this categorization and of ultrasound in the diagnosis and subsequent management of these patients is presented.