Long-term remission of clear cell carcinoma of the cervix after chemoradiation with 109 cycles of paclitaxel: a case report and literature review

BACKGROUND

Clear cell carcinoma of cervix (CCCC) is a rare cervical neoplasm that is usually associated with diethylstilbestrol (DES) exposure in utero as a primary risk factor. Advanced stage disease typically has poor outcomes and no evidence-based approach exists to guide clinicians in treating this rare disease.

CASE

The authors report a case of locally advanced CCCC in a 37-year-old Caucasian female. She underwent chemoradiation therapy that included 109 courses of paclitaxel chemotherapy until no disease could be detected on imaging studies. She is now disease-free 13 years after discontinuing chemotherapy.

CONCLUSION

A prolonged course of single agent paclitaxel after completing standard radiation therapy was successful in achieving remission in a patient with this rare disease.

Phase III trial of induction gemcitabine (G) or paclitaxel (T) plus carboplatin (C) followed by elective T consolidation in advanced ovarian cancer (OC): Final safety and efficacy report

LBA5008

Background: Safety and efficacy of GC or TC induction followed by elective T consolidation (Tcon) were evaluated.

Methods: Patients (pts) with stage IC-IV epithelial OC were randomized to GC: G 1,000 mg/m2 on days 1, 8 plus C AUC=5 on day 1; or TC: T 175 mg/m2 plus C AUC=6 on day 1 for a total of six 21-day cycles. Pts with a complete response (CR) could receive Tcon 135 mg/m2every 28 days for 12 cycles. Non-CR pts received single-agent crossover (CO) therapy (CO-T 175 mg/m2 on day 1 or CO-G 1,000 mg/m2 on days 1, 8) every 21 days until CR or progression of disease (PD). PD or death in 636 pts was required to compare GC and TC with 80% power for progression-free survival (PFS), the primary endpoint. Efficacy results were compared by log-rank test.

Results: The trial was stopped in 8/2009 after an ad hoc futility analysis showed low probability of a positive PFS result. Of 919 pts enrolled, 88 pts were excluded (clerical errors); 831 pts were entered; 820 pts had induction; 352 pts had Tcon (GC-Tcon=169, TC-Tcon=183); 155 pts had crossover (CO-T=77, CO-G=78); 313 pts discontinued after induction (GC=165, TC=148). Baseline pt characteristics were balanced across arms. Overall response and adverse events for induction regimens were similar to interim results (Gordon, Clin Ovar Cancer, 2009). For GC and TC, median PFS were 20.0 and 22.2 months; median overall survival (OS) were 43.8 and 57.3 months, respectively. There was no significant difference in PFS (p=0.199) comparing GC and TC. Despite high censorship (GC: 52.8%, TC: 61.4%), OS was greater for TC (p=0.013) compared to GC, but there was no statistical difference after adjusting for significant covariates. For pts with CR, median OS was 65.6 months with Tcon versus 51.4 months without Tcon (p=0.041). Median OS was not reached for TC-Tcon and was 56.1 months for GC-Tcon (p=0.035). For pts not receiving Tcon or receiving either CO-T or CO-G crossover, there was no difference in OS.

Conclusions: PFS was similar for GC and TC. Tcon improved OS. However, OS analysis was limited by study design and high censorship. GC does not offer an advantage over standard of care TC for first-line chemotherapy in advanced OC.

No significant financial relationships to disclose.

Efficacy and safety of erlotinib HCl, an epidermal growth factor receptor (HER1/EGFR) tyrosine kinase inhibitor, in patients with advanced ovarian carcinoma: results from a phase II multicenter study

The aim of this single-arm, phase II study was to estimate the tumor response rate and safety profile of erlotinib HCl (erlotinib, Tarceva, OSI-774) monotherapy in patients with refractory, recurrent, HER1/EGFR-positive epithelial ovarian tumors, who had failed prior taxane and/or platinum-based chemotherapy. Thirty-four patients received 150 mg erlotinib orally once daily for up to 48 weeks or until disease progression or dose-limiting toxicity. Two patients had partial responses, lasting 8+ and 17 weeks, giving an objective response rate of 6% (95% confidence interval [CI], 0.7-19.7%). Fifteen patients (44%) had stable disease, and 17 patients (50%) had progressive disease. Median overall survival was 8 months (95% CI, 5.7-12.7 months), with a 1-year survival rate of 35.3% (95% CI, 19.8-53.5%). Patients with rash survived significantly longer than those without (P= 0.009), correlating with rash grade. Erlotinib was generally well tolerated. The most frequent erlotinib-related adverse events were rash (68%) and diarrhea (38%). Erlotinib had marginal activity but was generally well tolerated. The safety profile appears more favorable than typically experienced with standard chemotherapeutic agents, which is encouraging in these heavily pretreated patients. Combination of erlotinib with chemotherapy or other targeted agents should be considered.

Recurrent epithelial ovarian carcinoma: a randomized phase III study of pegylated liposomal doxorubicin versus topotecan

PURPOSE

To compare the efficacy and safety of pegylated liposomal doxorubicin (PLD) and topotecan in patients with epithelial ovarian carcinoma that recurred after or didn't respond to first-line, platinum-based chemotherapy.

PATIENTS AND METHODS

Patients with measurable and assessable disease were randomized to receive either PLD 50 mg/m(2) as a 1-hour infusion every 4 weeks or topotecan 1.5 mg/m(2)/d for 5 consecutive days every 3 weeks. Patients were stratified prospectively for platinum sensitivity and for the presence or absence of bulky disease.

RESULTS

A total of 474 patients were treated (239 PLD and 235 topotecan). They comprised the intent-to-treat population. The overall progression-free survival rates were similar between the two arms (P =.095). The overall response rates for PLD and topotecan were 19.7% and 17.0%, respectively (P =.390). Median overall survival times were 60 weeks for PLD and 56.7 weeks for topotecan. Data analyzed in platinum-sensitive patients demonstrated a statistically significant benefit from PLD for progression-free survival (P =.037), with medians of 28.9 for PLD versus 23.3 weeks for topotecan. For overall survival, PLD was significantly superior to topotecan (P =.008), with a median of 108 weeks versus 71.1 weeks. The platinum-refractory subgroup demonstrated a nonstatistically significant survival trend in favor of topotecan (P =.455). Severe hematologic toxicity was more common with topotecan and was more likely to be associated with dosage modification, or growth factor or blood product utilization.

CONCLUSION

The comparable efficacy, favorable safety profile, and convenient dosing support the role of PLD as a valuable treatment option in this patient population.

Phase II study of liposomal doxorubicin in platinum- and paclitaxel-refractory epithelial ovarian cancer

PURPOSE

Stealth liposomal doxorubicin (Alzal Corp, Palo Alto, CA) has a slower clearance rate than free doxorubicin, resulting in sustained serum levels. Liposomal encapsulation also leads to increased concentration of drug in tumor tissue. Meta-analysis of previous studies has shown that doxorubicin has activity in epithelial ovarian cancer. The current study was developed to examine the activity of Stealth liposomal doxorubicin in platinum- and paclitaxel-refractory ovarian cancer.

PATIENTS AND METHODS

Patients had epithelial ovarian cancer that either progressed on or recurred within 6 months of completion of platinum and paclitaxel chemotherapy. All patients had measurable disease. Stealth liposomal doxorubicin was administered at 50 mg/m(2) every 4 weeks as a 1-hour infusion.

RESULTS

Eighty-nine patients were treated and included in an intent-to-treat analysis. There were 82 patients who were platinum and paclitaxel refractory and met all study criteria. There was one complete response and 14 partial responses, for a total response rate of 16.9% (95% confidence interval [CI], 9.1% to 24.6%). For platinum- and paclitaxel-refractory patients, the response rate was 18.3% (95% CI, 9.9% to 26.7%). Median time to progression was 19. 3 weeks for the entire population. Ten patients (11.2%) withdrew because of adverse events related to the drug (palmar-plantar erythrodysesthesia [PPE], n = 3; asthenia, n = 2; cardiac, n = 2; neutropenia, n = 1; stomatitis, n = 1; and edema, n = 1). There were no drug-related fatal events. There were only eight grade 4 adverse events attributable to the drug. Stomatitis, PPE, and skin lesions were managed with dose reductions and delays in most cases.

CONCLUSION

Stealth liposomal doxorubicin has activity in refractory epithelial ovarian cancer. PPE and stomatitis can usually be managed by dose adjustment. The ease of administration makes this an attractive agent.

A phase I/II dose escalation study of carboplatin in the treatment of newly diagnosed patients with advanced ovarian cancer receiving paclitaxel

The objective of this study was to determine the maximum tolerated dose of carboplatin when administered with paclitaxel in previously untreated patients with ovarian cancer. Patients were treated with paclitaxel at 225 mg/m2 for 3 hours followed by carboplatin at an area under the curve (AUC) of 6, 7, 8, or 9 every 3 weeks. Granulocyte colony-stimulating factor was added if needed to maintain dose intensity before dose reductions were used for grade 4 hematologic toxicity or febrile neutropenia. Twenty-two patients were enrolled in the study. At the AUC 6 level, five of six patients finished all six cycles. At the AUC 7 level, four of five patients completed six cycles, although three required dose reductions for toxicity. At the AUC 8 level, all four patients completed six cycles and two required dose reductions. The AUC 9 level was not well tolerated. Only four of seven patients completed six cycles. Neutropenia was common, and transient thrombocytopenia was more severe and required dose reduction, especially in later cycles. An AUC of 8 is the maximum tolerated dose of carboplatin in combination with paclitaxel at 225 mg/m2 for 3 hours.

Hapalotrema (Digenea: Spirorchidae) in the green turtle (Chelonia mydas) in Australia

Hapalotrema mehrai Rao, 1976 and Hapalotrema postorchis Rao, 1976 (Digenea: Spirorchidae) are redescribed from the heart and pulmonary arteries of the green turtle, Chelonia mydas, from Moreton Bay in south-eastern Queensland. Hapalotrema pambanensis Gupta and Mehrotra, 1981 from C. mydas in India is made a synonym of H. mehrai. Hapalotrema dorsopora Dailey, Fast and Balazs, 1993 from C. mydas from Hawaii was described with a dorsally opening uterine pore, but this is found to be the opening of Laurer's canal; therefore H. dorsopora is also made a synonym of H. mehrai. In addition to differences in the numbers of testes and general dimensions, H. mehrai and H. postorchis differ in the development of Laurer's canal and in the absence of a canalicular seminal receptacle in H. postorchis.

Lesions caused by cardiovascular flukes (Digenea: Spirorchidae) in stranded green turtles (Chelonia mydas)

Evidence of infection with spirorchid flukes (Digenea: Spirorchidae) was sought at necropsy of 96 stranded green turtles, Chelonia mydas, that were examined during the course of a survey of marine turtle mortality in southeastern Queensland, Australia. Three species of spirorchid (Hapalotrema mehrai, H. postorchis, and Neospirorchis schistosomatoides) were identified. Severe disease due to spirorchid fluke infection (spirorchidiasis) was implicated as the principal cause of mortality in 10 turtles (10%), and appeared to be one of multiple severe problems in an additional 29 turtles (30%). Although flukes were observed in only 45% of stranded C. mydas in this study, presumed spirorchid fluke infection was diagnosed in an additional 53% of turtles, based principally on characteristic necropsy lesions and to a lesser extent on the histopathological detection of spirorchid eggs. Characteristic necropsy lesions included miliary spirorchid egg granulomas, which were observed most readily on serosal surfaces, particularly of the small intestine. Cardiovascular lesions included mural endocarditis, arteritis, and thrombosis, frequently accompanied by aneurysm formation. Resolution of thrombi was observed to occur via a combination of granuloma formation about indigestible components (spirorchid fluke egg shells) and exteriorization through the vessel wall, which resulted in granulomatous nodules on the adventitial surface. Septic aortic thrombosis complicated by disseminated bacterial infection, observed in five turtles, was recorded for the first time. Egg granulomas were ubiquitous in turtle tissues throughout this study. Although they generally appeared to be mild or incidental lesions, they were occasionally associated with severe multifocal granulomatous pneumonia or meningitis.

An outbreak of malignant catarrhal fever in young rusa deer (Cervus timorensis)

On the basis of clinical signs and histological findings eight 9-month-old male rusa deer (Cervus timorensis) were diagnosed with sheep associated-malignant catarrhal fever. Following a variable course involving rectal temperatures around 40.5 degrees C, depression, inappetence, diarrhoea, corneal opacity and hypopyon all animals died or were euthanased over a 5-week period. Severe multifocal vasculitis, mainly periglomerular and in the arcuate vessels were consistent histological findings which in the past have been adequate to confirm clinical diagnosis of sheep associated-malignant catarrhal fever. A nested polymerase chain reaction test has been used to detect a sheep associated-malignant catarrhal fever PRC product, 238 base-pairs in size, in DNA extracted from lymphocyte preparations. The result supported the diagnosis of sheep associated-malignant catarrhal fever in these deer.

Phase I dose escalation of paclitaxel in patients with advanced ovarian cancer receiving cisplatin: rapid development of neurotoxicity is dose-limiting

PURPOSE

To determine the maximum-tolerable dose (MTD) of paclitaxel in a phase I dose-escalation study when combined with cisplatin in patients with advanced ovarian cancer receiving filgrastim for prophylaxis of myelosuppression.

PATIENTS AND METHODS

A total of 23 patients with stage II (bulky residual), III, or IV epithelial ovarian cancer were treated (following debulking surgery) with paclitaxel as a 3-hour infusion followed by cisplatin (75 mg/m2) administered over 4 hours on day 1, repeated every 21 days for six cycles. Filgrastim (5 micrograms/kg/d) was administered subcutaneously (SC) beginning on day 2 of each cycle through neutrophil recovery (absolute neutrophil count [ANC] > 10,000/microL). Patients were assigned to one of six escalating dose levels of paclitaxel: 150 (n = 3), 175 (n = 3), 200 (n = 3), 225 (n = 4), 250 (n = 4), and 275 mg/m2 (n = 6).

RESULTS

At each paclitaxel dose level (150, 175, 200, 225, 250, and 275 mg/m2), the numbers of patients who completed six cycles without dose reduction were three (100%), three (100%), two (66%), two (50%), three (75%), and zero (0%), respectively. The numbers of patients who experienced a grade III/IV adverse event (hematologic or nonhematologic) were zero (0%), two (66%), two (66%), one (25%), four (100%), and five (80%), respectively. Reasons for dose reduction included neurotoxicity (225 mg/m2, n = 1; 275 mg/m2, n = 2), neutropenia (225 mg/m2, n = 2), diarrhea (275 mg/m2, n = 2), and nephrotoxicity (225 mg/m2, n = 1). Reasons for not completing six cycles at full or reduced dose included neuropathy (200, 225, and 275 mg/m2, n = 1 each) physician request (275 mg/m2, n = 1), and death (275 mg/m2, n = 1). Hematopoietic toxicity was minimal. Six patients developed grade III/IV neutropenia. No patient developed thrombocytopenia below a level of 50,000/microL.

CONCLUSION

The MTD of paclitaxel was determined to be 225 mg/m2 when administered as a 3-hour infusion and combined with cisplatin (75 mg/m2). Nonhematologic dose-limiting toxicities were neuropathy and diarrhea. The neuropathy often had a rapid onset, especially at the higher dose levels.

Abundane of macropods in north-eastern New South Wales, and the logistics of broad-scale ground surveys

A broad-scale ground survey of macropod abundance in north-eastern New South Wales was undertaken in 1989-90. The survey area was stratified into an eastern and western region, and within regions by habitat on the basis of vegetation and topographic criteria. Macropod density in each stratum was estimated from walked line transect counts for five species: Macropus giganteus, Macropus robustus, Macropus parryi, Macropus rufogriseus and Wallabia bicolor. Within sampled strata, macropod density was substantially higher in the western region than in the eastern region. Macropus parryi occurred in only trace numbers in the eastern region, with the number of sightings too small for reliable density estimation. No M. parryi were sighted in the western region. Macropus giganteus and M. rufogriseus were the dominant species in sampled strata in the eastern region, while M. giganteus and M. robustus were dominant in the west. Overall, pre-survey activities of habitat digitising and liaison with landholders required approximately the same effort as actual survey work. Liaison with landholders required relatively more time in the eastern region, where human population was higher, than in the western region. Incomplete coverage of planned transect routes, due mainly to impenetrable vegetation, lead to a positive bias of no more than 10-20% in population estimation for M. giganteus and M. robustus, and an unknown bias for the other species. The use of broad vegetation information on 1 : 100 000 map sheets for habitat stratification limited the scale at which analysis of sightability could be undertaken. Macropus giganteus and M. robustus are commercially harvested in the western region. Annual commercial harvest rates in the three years prior to the survey were conservatively estimated to be less than 0.9% for M. robustus and less than 5.4% for M. giganteus.

Epizootic mortality of free-living green turtles, Chelonia mydas, due to coccidiosis

At least 70 wild green sea turtles, Chelonia mydas, died in the Moreton Bay area of southeast Queensland, Australia over 6 wk in spring 1991. Based on the necropsy of 24 turtles, there was a severe enteritis or encephalitis associated with Caryospora cheloniae, a coccidial pathogen previously recorded only in farm-reared Ch. mydas hatchlings. Infection was characterized by the presence of coccidia in extra-intestinal lesions. Oocysts were observed to sporulate, after which sporozoites escaped into seawater to form a novel stellate configuration. We conclude that C. cheloniae is pathogenic for life stages other than hatchling Ch. mydas and that naturally-occurring coccidiosis is a significant disease of free-living Ch. mydas.

Suicide by poisoning

An epidemiological evaluation was conducted on 270 patients who died at the General Hospital, Port-of-Spain after presenting with deliberate self-poisoning between January, 1986 and June, 1990. The cause of death was confirmed by autopsy and toxicological analysis. Epidemiological variables of age, sex, race, precipitating factors and types of poison used were assessed. It was found that the male to female ratio was 2.7:1. East Indians accounted for 54.4%, Africans 42.0%, people of mixed ethnic origin 3% and Caucasians 0.6%. The majority of cases (52.6%) were seen in the age group 11-34 years. "Lovers' quarrels" (35.4% of cases), psychiatric illness (27.8% of cases) and family disputes (27% of cases) were reported as the most frequent precipitating events in suicide. East Indians predominated in those suicides precipitated by "lovers' quarrels" and family disputes, accounting for 63.2% and 58.9% of these cases, respectively; while for those suicides in which psychiatric illnesses were the main precipitating event. Africans were represented by 53.3% and East Indians 45.3%. Depression was the most common psychiatric illness diagnosed. Paraquat was the most popular poison used in 63.7% of the suicidal cases, and other agrochemicals were used in 20% of cases.

Depth of myometrial invasion in endometrial cancer: preoperative assessment by transvaginal ultrasonography

Twenty-five patients with cancer of the uterus underwent transvaginal sonography (TVS) to assess depth of myometrial invasion. All scans were performed with a 5.0-MHz curvilinear array probe (Toshiba, Inc., Tustin, CA) within 1 week of hysterectomy. In 21 cases (84%) sonography correctly predicted the depth of invasion (within 15% of actual). Only one of three cases with cervical involvement was detected. Transvaginal sonography can accurately detect depth of myometrial invasion and is well suited as a screening test to detect high-risk patients for consultation or referral.

Adjuvant chemotherapy with cisplatin, doxorubicin, and cyclophosphamide (PAC) for early-stage high-risk endometrial cancer: a preliminary analysis

Between October 1985 and January 1989, 33 patients with stage I (31) or clinically occult stage II (2) endometrial cancer at a high risk for recurrence were entered in a prospective study evaluating adjuvant cisplatin, doxorubicin, and cyclophosphamide (PAC) chemotherapy. Eligibility criteria included grade 2 tumors with middle- or outer-third myometrial invasion (16), grade 3 tumors with any degree of myometrial invasion (17), presence of extrauterine disease with no gross residual (17), or a high-risk histologic subtype including papillary serous (4), adenosquamous (5), or clear cell (1) tumors. Patients received PAC (50/50/500 mg/m2) at 4-week intervals for six cycles. Thirty patients (90%) completed therapy. Toxicity included severe neutropenia in 14 patients, neutropenic sepsis in 2 patients, and doxorubicin-related cardiomyopathy in 1 patient. There were no treatment deaths. Current median follow-up is 25 months. Nine patients (27%) have developed a recurrence, 7 of whom died, after a median interval of 14 months. Eight of the 9 with recurrence initially had extrauterine disease (P = 0.02). The resulting 2-year actuarial progression-free and overall survival rates were 79 and 83%, respectively. The median progression-free interval was 29 months for patients with extrauterine disease and 45+ months for those with no extrauterine disease (P = 0.02). These results suggest that a phase 3 randomized trial comparing adjuvant PAC with radiation therapy is warranted.

Survival after malignant pericardial effusion and cardiac tamponade in advanced ovarian cancer

Malignant pericardial effusion and tamponade are rarely seen complications of epithelial ovarian cancer. With the use of multiagent chemotherapy these complications may be seen more frequently in the future. Therapy should be individualized, as long-term survival may be possible if the systemic manifestations of the cancer can be controlled.

Sarcoma botryoides of the cervix: excision followed by adjuvant chemotherapy for preservation of reproductive function

Sarcoma botryoides is most often seen arising in the infantile vagina. Occasionally, disease will arise in the cervix in the adolescent. Most patients have been treated by radical surgery combined with multiagent chemotherapy. We recently treated a patient by local excision followed by multiagent chemotherapy in an attempt to preserve reproductive potential. The present case and a review of the literature suggest that excisional therapy with subsequent chemotherapy should be adequate for localized disease.

Self-instruction to prevent HIV infection among African-American and Hispanic-American adolescents

This study tested the efficacy of self-instruction intervention to reduce avoidable risks for HIV infection associated with drug use and unsafe sexual activity among African-American and Hispanic adolescents (N = 60). After completing pretests, adolescent participants in the study were randomly divided into three conditions. Participants in one condition received a self-instructional guide about AIDS and its transmission along with group instruction in using the guide. Adolescents in another condition received the guide without group instruction. Participants in the third condition received neither the guide nor group instruction. Outcome findings indicate that participants in the two self-instruction conditions improved more between pretest and posttest assessments on measures of HIV infection risk compared with adolescents in the control condition.

Human papillomavirus associated with adenocarcinoma and adenosquamous carcinoma of the cervix: analysis by in situ hybridization

The incidence of adenocarcinoma of the cervix appears to be increasing. Recent reports have demonstrated an association between adenocarcinoma of the cervix and human papillomavirus (HPV) by Southern blot hybridizations. In situ deoxyribonucleic acid (DNA) hybridization was performed on paraffin-embedded specimens to localize the source of HPV DNA. In pure adenocarcinoma five of six specimens were positive for HPV DNA. Four specimens contained HPV type 18 and one HPV type 16. Only one of three adenosquamous lesions was positive and it contained both HPV types 16 and 31. These findings suggest an association between HPV and adenocarcinoma of the cervix.

Response of lower genital tract flora to external pelvic irradiation

Endocervical and vaginal cultures were obtained every week from patients undergoing external pelvic irradiation for gynecologic malignancy. Gram-positive aerobes accounted for 52 to 56% of isolates, gram-negative aerobes accounted for 15 to 16%, and anaerobes accounted for 29 to 32% of all isolates prior to therapy. No significant changes occurred during or after completion of radiation for the group. In individual patients, however, over 50% of organisms found on initial culture were no longer present on completion of external therapy.

Preoperative assessment of myometrial invasion of endometrial adenocarcinoma by sonography (US) and magnetic resonance imaging (MRI)

The presence and/or depth of myometrial invasion of endometrial adenocarcinoma has important prognostic and therapeutic implications. Fifteen patients with histologically proven endometrial cancer underwent preoperative evaluation with sonography (US) and magnetic resonance imaging (MRI) to assess depth of invasion. Using criteria of greater than or equal to 50% of myometrial wall involvement as representing deep invasion, and less than 50% as superficial invasion, US was more accurate than MRI in five cases; in three MRI was more accurate than US; both MRI and US were equally accurate in four; neither was accurate in three. Polypoid lesions caused the greatest number of false positive reports of deep invasion with both MRI and US. Preliminary results indicate that US and MRI have promise as preoperative tests to assess the extent of myometrial invasion.

High-risk metastatic gestational trophoblastic disease: further stratification into two clinical entities

Forty-two of sixty-seven patients (62.7%) treated for high-risk metastatic trophoblastic disease achieved and maintained complete remissions. The survival rate was significantly improved in those patients with scores lower than 8 according to a modification of the World Health Organization (WHO) prognostic scoring system. A low score was associated with a higher probability of response to single-agent therapy, although the difference was not statistically significant. The score, however, was significantly associated with response to multiagent chemotherapy with methotrexate, actinomycin D, and cyclophosphamide (P = 0.0004). Therefore, future trials of new combinations of chemotherapy in high-risk patients should be stratified according to the patients' prognostic scores.

Squamous carcinoma of the cervix complicating pregnancy: recurrence in episiotomy after vaginal delivery

A patient developed recurrence of squamous carcinoma of the cervix in the episiotomy scar after vaginal delivery through the involved cervix. At the time of her radical hysterectomy, all margins and nodes were free of tumor, suggesting implantation at delivery as the etiology of the recurrence. Review of the literature revealed three other cases of episiotomy recurrence. All cases were either clinically unsuspected or had negative Papanicolaou tests during pregnancy. Careful surveillance and early therapy appear to give a more favorable prognosis for this unusual type of recurrence.

Primary malignant melanoma of the vagina: report of four cases and review of the literature

Four cases of malignant melanoma arising in the vagina are described, and the literature related to this unusual tumor is reviewed. The 2-year survival rate is better following radical surgery than after other treatment modalities; however, the 5-year survival rate is unrelated to type of therapy. Radical surgery appears to control local disease, but fails to address systemic spread of the tumor. Therefore, improvement in survival will require effective systemic therapy.

Conservative management of abdominal gunshot wound in a pregnant woman

An abdominal gunshot wound in pregnancy warrants prompt surgical exploration but does not mandate uterine evacuation. Despite an entry and exit bullet wound to the uterus an apparent desire for pregnancy termination, a conservative approach was adopted with primary repair of the uterus, in conjunction with surgical repair of associated injuries.

Small-cell carcinoma of the ovary: an aggressive epithelial cancer occurring in young patients

A case of small-cell carcinoma of the ovary occurring in a 33-year-old patient is described. At no time did the patient develop hypercalcemia. Despite aggressive cytoreductive surgery and multiagent chemotherapy, the patient expired after 13 months. These lesions must be differentiated from germ cell tumors or lymphoma. Review of the literature fails to reveal effective adjuvant therapy.

Sigmoidovaginal fistula secondary to diverticular disease. A report of three cases

Colovaginal fistula from any cause is rare. Diverticular disease is the most common cause. We treated three women for sigmoidovaginal fistulae secondary to diverticular disease. These 3 cases bring the total number reported to 49. Diagnosis of these fistulae may be difficult, and controversy exists over which form of surgical management should be employed. Since more women are living to an age at which diverticular disease is common, colovaginal fistulae probably will be encountered by the gynecologist with increasing frequency. Colovaginal fistula secondary to diverticular disease should be considered in the differential diagnosis when an elderly women complains of flatus vaginalis.

Detection of human papillomavirus DNA in advanced epithelial ovarian carcinoma

Tissue specimens from 10 out of 12 patients with advanced epithelial ovarian adenocarcinoma contained DNA of human papillomavirus type 6 (HPV-6). HPV DNA was identified by in situ hybridization at high stringency using biotin-labeled DNA probes. Nonneoplastic tissue specimens from other pelvic sites of the same patients were also examined. None showed evidence of HPV DNA. The meaning of these findings in relation to epithelial ovarian carcinoma is discussed.

Cisplatin, vinblastine, and bleomycin combination therapy in resistant gestational trophoblastic disease

Eleven patients were treated with cisplatin, vinblastine, and bleomycin (PVB) combination chemotherapy after failure of conventional triple-agent therapy with methotrexate, dactinomycin, and cyclophosphamide for gestational trophoblastic disease. Of ten evaluable patients, five (50%) achieved negative titers. Sustained remission was achieved in only two patients (20%). Major hematologic toxicities and two deaths due to sepsis occurred in this group of patients. Although this combination does exhibit activity, its clinical use in the treatment of refractory trophoblastic disease is limited.

High-risk metastatic gestational trophoblastic disease

The clinical course of 61 patients with high-risk metastatic gestational trophoblastic disease was reviewed. Currently, 34 patients (56%) are alive and in complete remission. The survival rate after full-term pregnancy was significantly worse than after any other type of antecedent pregnancy. Analyzing survival by individual high-risk criteria revealed significantly improved survival for those patients with elevated beta-human chorionic gonadotropin titer alone when compared with all other high-risk criteria. Fifty-eight percent of patients (14 of 24) primarily treated with alternating-sequential therapy consisting of methotrexate and actinomycin-D experienced a complete remission. Of those patients primarily treated with methotrexate, actinomycin-D, and cyclophosphamide, 63% (20 of 32) achieved a complete remission. Treatment with second-line chemotherapy was largely unsuccessful. Aggressive early treatment is warranted in this group of patients, using multiagent chemotherapy. A search for newer more effective regimens should continue.

Successful treatment of leptomeningeal relapse of epithelial ovarian cancer

A case of isolated leptomeningeal recurrence of an epithelial ovarian cancer was recently diagnosed and treated successfully with methotrexate placed via an Ommaya reservoir in combination with radiation therapy. A review of the literature revealed no other cases of epithelial ovarian leptomeningeal malignancy similarly treated.