Radiation ±cisplatin for bulky stage IB cervical carcinoma; Long-term follow-up of a GOG trial

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Purpose: To confirm that concurrent cisplatin (CT) with radiation (RT) is associated with improved long-term progression-free survival (PFS), overall survival (OS), and decreased morbidity compared to RT stage IB bulky carcinoma of the cervix, when both groups’ therapy is followed by hysterectomy. Methods: Three hundred seventy-four patients entered this trial. There were 369 evaluable patients; 186 were randomly allocated to receive RT alone and 183 to receive CT+RT. Radiation dosage was 40 Gray (Gy) in 20 fractions followed by a single low dose-rate intracavitary application of 30 Gy to Point A. Chemotherapy consisted of cisplatin 40 mg/M2 every week for up to six weekly cycles. Total extrafascial hysterectomy followed the completion of RT by 3–6 weeks. Results: Preliminary results have been published, at which time there many censored observations and limited follow-up. Patient and tumor characteristics were well-balanced between the regimens. The median patient age was 41.5 years; 81% had squamous tumors; 59% were white. Median follow-up is 101 months. The relative risk for progression was 0.61 favoring CT+RT (95% confidence interval [CI]: 0.43–0.85, p < 0.004). At 72 months 71% of patients receiving CT+RT were predicted to be alive and disease-free when adjusting age and for tumor size compared to 60% of those receiving RT alone. The adjusted death hazard ratio was 0.63 (95% CI: 0.43–0.91, p < 0.015) favoring CT+RT. At 72 months, 78% of CT+RT patients were predicted to be alive compared to 64% of RT patients. An increased rate of early hematologic and gastrointestinal toxicity was seen with CT+RT. There was no detectable difference in the frequency of late adverse events. Conclusion: Concurrent weekly cisplatin with RT significantly improves long term PFS and OS when compared to RT alone. Serious late effects were not increased. The inclusion of hysterectomy has been discontinued on the basis of another trial. Pending further trials, weekly cisplatin with radiation is the standard against which other regimens must be compared. Key Words: Cervical carcinoma, chemoradiotherapy.

No significant financial relationships to disclose.

Recurrent ascites and pleural effusions after surgery for early-stage endometrial adenocarcinoma

A case of massive postoperative ascites in a woman treated for endometrial cancer is reported. A workup for typical causes of ascites yielded negative results, prompting a more detailed analysis of the patient's condition. Hypothyroidism was discovered. After correction of the hypothyroidism, the ascites slowly resolved. Since myxedema is an uncommon cause of ascites, this is usually a diagnosis of exclusion. However, hypothyroidism must be ruled out to prevent unnecessary and possibly inappropriate treatments for ascites.

Preoperative chemoradiation for advanced vulvar cancer: a phase II study of the Gynecologic Oncology Group

PURPOSE

To determine the feasibility of using preoperative chemoradiotherapy to avert the need for more radical surgery for patients with T3 primary tumors, or the need for pelvic exenteration for patients with T4 primary tumors, not amenable to resection by standard radical vulvectomy.

METHODS AND MATERIALS

Seventy-three evaluable patients with clinical Stage III-IV squamous cell vulvar carcinoma were enrolled in this prospective, multi-institutional trial. Treatment consisted of a planned split course of concurrent cisplatin/5-fluorouracil and radiation therapy followed by surgical excision of the residual primary tumor plus bilateral inguinal-femoral lymph node dissection. Radiation therapy was delivered to the primary tumor volume via anterior-posterior-posterior-anterior (AP-PA) fields in 170-cGy fractions to a dose of 4760 cGy. Patients with inoperable groin nodes received chemoradiation to the primary vulvar tumor, inguinal-femoral and lower pelvic lymph nodes.

RESULTS

Seven patients did not undergo a post-treatment surgical procedure: deteriorating medical condition (2 patients); other medical condition (1 patient); unresectable residual tumor (2 patients); patient refusal (2 patients). Following chemoradiotherapy, 33/71 (46.5%) patients had no visible vulvar cancer at the time of planned surgery and 38/71 (53.5%) had gross residual cancer at the time of operation. Five of the latter 38 patients had positive resection margins and underwent: further radiation therapy to the vulva (3 patients); wide local excision and vaginectomy necessitating colostomy (1 patient); no further therapy (1 patient). Using this strategy of preoperative, split-course, twice-daily radiation combined with cisplatin plus 5-fluorouracil chemotherapy, only 2/71 (2.8%) had residual unresectable disease. In only three patients was it not possible to preserve urinary and/or gastrointestinal continence. Toxicity was acceptable, with acute cutaneous reactions to chemoradiotherapy and surgical wound complications being the most common adverse effects.

CONCLUSION

Preoperative chemoradiotherapy in advanced squamous cell carcinoma of the vulva is feasible, and may reduce the need for more radical surgery including primary pelvic exenteration.

Management of the adnexal mass in the 1990s

BACKGROUND

Ovarian carcinoma is the leading cause of deaths from female genital cancers in the United States. During the last three decades, advances in diagnostic techniques, surgical techniques, and adjuvant chemotherapy have led to improved survival in some patients who have an adnexal mass that is later diagnosed as malignant.

METHODS

A review of the current technique, compiled with our changing management, was done to help identify possible pitfalls in the initial management of the adnexal mass in specific age groups. The expensive and controversial issues such as screening, management of patients with a genetic history, and management with laparoscopy were reviewed.

RESULTS

Appropriate initial surgery improves survival in patients with adnexal masses, later determined to be malignant, particularly when adjuvant, modern combination chemotherapy is used. Laparoscopy for suspicious adnexal masses cannot be condoned, unless immediate appropriate surgical staging can be done.

CONCLUSIONS

Awareness and implementation of current diagnostic and treatment modalities can improve survival in the patient with an adnexal mass that is later found to be malignant.

An update on the diagnosis and treatment of common malignant ovarian tumors

Malignant ovarian tumors are the second most common female type of genital tract cancers, and they are the leading cause of death of women with such malignancies. Over the last 2 decades, advances in epidemiology, diagnostic techniques, and treatment have led to earlier diagnoses and to improved survival, particularly for patients with germ cell tumors. The purpose of this review is to acquaint practicing physicians with the advantages and pitfalls of 1990's diagnostic techniques and to guide them on when to refer. Emphasis will be given to performing the appropriate operation the first time. Adjuvant chemotherapy with newer combined regimens may improve survival in some patients with epithelial ovarian cancer and has been shown to improve survival in patients with germ cell tumors.

Characteristics of patients with rapidly growing cervical cancer

Between April 1983 and December 1990, 387 newly diagnosed cervical cancer cases were managed at our institution. We retrospectively reviewed 59 of those cases, which were identified as having developed within 3 years of the patients' last normal Pap smear. Squamous cell carcinoma was found in 45 patients, and 33 had poorly differentiated lesions. Six cases had typical histology. However, 27 cases (82%) had distinctive histologic features that have not been previously described in rapidly progressive cervical cancer. Thirty-seven patients had surgical treatment; 7 (19%) died of disease. Twenty-two patients had radiation; 10 (45%) died of disease. Patients who have invasive cervical cancer after a recent normal Pap smear may have unusual histologic types, and some with early-stage disease may have better outcome if treated with radical surgery.

Human chorionic gonadotrophin-beta gene sequences in women with disorders of HCG production

Women with recurrent abortion, primary unexplained infertility, and gestational trophoblastic neoplasia (GTN) manifest disordered human chorionic gonadotrophin (HCG) secretion. Mutations in the HCG beta/luteinizing hormone (LH) beta gene complex could cause aberrant HCG production in these disorders. The purpose of this study was to determine whether HCG beta gene deletions occur in women with recurrent abortion or primary unexplained infertility, and whether HCG beta gene duplications are present in women with GTN. DNA was extracted from 10 patients with unexplained recurrent abortion, 10 patients with unexplained primary infertility, 12 patients with GTN, three partners of women with GTN, and 30 controls. Southern blots were constructed and hybridized with DNA probes for HCG beta-5 and the LH beta gene. No gene deletions were identified in patients with recurrent abortion or primary unexplained infertility. Likewise, no gene duplications were identified in women with GTN. A previously described Mbol restriction fragment length polymorphism (RFLP) was identified in both patients and controls. A new Pstl RFLP was also characterized, but was present in patients and controls. Deletion/duplication mutations in the HCG beta/LH beta gene complex do not appear to be common causes of aberrant HCG production in humans with these disorders.

A phase II trial of 5-fluorouracil and high-dose leucovorin in patients with recurrent squamous cell carcinoma of the cervix: a Gynecologic Oncology Group study

The addition of leucovorin to 5-fluorouracil (5-FU) has been shown to improve the response rate in recurrent colon cancer. The combination of low-dose leucovorin and 5-FU was previously tested by the Gynecologic Oncology Group (GOG) and did not produce response rates greater than rates using 5-FU alone. From June 1990 to April 1992, 55 patients with unresectable recurrent squamous cervical cancer received high-dose leucovorin at 200 mg/m2 i.v. bolus, followed by 5-FU at 370 mg/m2 i.v. bolus daily for 5 days every 4 weeks for the first two courses. Subsequent courses were given every 5 weeks. The median number of courses delivered was two (range 1-15). Fifty patients were evaluable for toxicity and 45 for response. Prior radiotherapy had been given to 43 patients and prior chemotherapy to 38. The overall response rate was 8.8% (95% confidence interval, 2.5-21.2%). There were two complete responses (4.4%) and two partial responses (4.4%). One response was in the pelvis and three were outside the pelvis. None of the extrapelvic responses had received irradiation at the site of measurable disease. The major adverse effect was granulocytopenia, with 15/50 (30%) experiencing GOG grade 3 or 4 granulocytopenia. The median white blood count for patients experiencing leukopenia was 2,000 (range 400-3,800). Grade 3 or 4 gastrointestinal toxicity was seen in 12 patients (24%). In this pretreated population, patients receiving high-dose leucovorin with 5-FU had moderate toxicity but only minimal activity.

Use of a subcutaneous closed drainage system and antibiotics in obese gynecologic patients

OBJECTIVE

The purpose of this study was to evaluate the effect of subcutaneous closed drainage systems and prophylactic antibiotics on the wound breakdown rate in obese patients undergoing gynecologic surgery.

STUDY DESIGN

A prospective study was performed on 197 obese patients who were randomly selected to have a subcutaneous drain. Incision closure technique was standardized. Antibiotic usage was not randomized. Demographic data, perioperative data, and postoperative complications were noted and analyzed by X2 test and 2 x 2 contingency tables.

RESULTS

The overall complication rate was 25%, with 20% (22/109) among the group receiving a drain versus 31% (27/88) without a drain. Seventeen patients (8.6%) had wound breakdowns: 7 of 109 (6.4%) with drains and 10 of 88 (11.4%) without drains. Prophylactic antibiotics were given to 46% (50/109) in the drain group and 51% (45/88) without a drain. Fewer patients (2%) with a drain receiving antibiotics had wound breakdowns. The group with the most breakdowns had neither a drain nor antibiotics (14%).

CONCLUSION

We suggest the use of subcutaneous drains plus prophylactic antibiotics may decrease morbidity when operating on obese gynecologic patients.

Mitotic count, nuclear atypia, and immunohistochemical determination of Ki-67, c-myc, p21-ras, c-erbB2, and p53 expression in granulosa cell tumors of the ovary: mitotic count and Ki-67 are indicators of poor prognosis

In spite of extensive research, the behavior of granulosa cell ovarian tumors remains unpredictable and is complicated by the lack of prognostic factors in early-stage disease. Forty patients with granulosa cell tumors were identified from tumor registries and data were analyzed for patient outcome. Mitotic count and nuclear atypia were determined at time of histological review. Paraffin-embedded archival tumor tissues from 32 of 40 patients were available, and immunohistochemical testing for Ki-67, c-myc, p21-ras, c-erbB2, and p53 was performed on archival tissues. Results were correlated with patients' outcome. Mitotic count and Ki-67 were found to be negatively associated with survival in granulosa cell tumors. Nuclear atypia, c-myc, p21-ras, c-erbB2, and p53 were not found to be of prognostic significance.

Carcinoma of the vulva in young women

OBJECTIVE

To determine if young women with carcinoma of the vulva have a different risk factor history and outcome compared with older women.

METHODS

We conducted a retrospective review of the medical records of 78 women treated at the Medical College of Georgia for squamous carcinoma of the vulva during 1979-1993. Women younger than 45 years were compared with those 45 and over for historic risk factors, treatment modality, and outcome.

RESULTS

Over the study interval, the average presenting age of these patients decreased from 69 to 55 years. Women under 45 were found to have a stronger history of condyloma (P < .001, 95% confidence interval [CI] 3.69-87.96). There was no significant difference by age in the duration of symptoms before presentation, smoking history, or tumor size. Women 45 and over were more likely to have advanced-stage disease (International Federation of Gynecology and Obstetrics [FIGO] stage III or IV) (P = .03, 95% CI 0.43-0.91). Treatment did not differ significantly with age. In a univariate analysis, advanced FIGO stage, presence of metastases, and tumor size were associated with shorter survival. There was no detected difference in survival for women in either age group.

CONCLUSION

There appears to be a trend in our patient population toward younger women presenting with squamous carcinoma of the vulva. Human papillomavirus infection appears to be more common in younger women with vulvar carcinoma. There may be a difference in the etiologies producing squamous carcinomas of the vulva. Education encouraging the early detection and prevention of sexually transmitted diseases might alter the rising incidence of this disease in younger women.

Phase II trial of mitomycin-C in squamous cell carcinoma of the uterine cervix: a Gynecologic Oncology Group study

Fifty-six patients with advanced, persistent, or recurrent squamous cell carcinoma of the cervix not previously exposed to cytotoxic drugs, other than as radiosensitizers, were entered into a study of single-agent 20 mg/m2 mitomycin-C every 6 weeks. The overall response rate among the 52 patients evaluable for response was 12% (three complete and three partial responses). Median response duration was 7.3 months. For the entire population, median progression-free interval was 3.0 months, and median survival was 4.9 months. Among 27 patients with pelvic disease only in previously radiated fields, two responses were observed (7%), whereas four responses were observed among 25 patients with extrapelvic disease in nonradiated fields (16%). The most frequent and severe adverse effects were the result of myelosuppression. Based on the modest level of activity observed, no further study of mitomycin-C in squamous cell carcinoma of the cervix is planned.

Long-term remission of previously resistant choriocarcinoma with a combination of etoposide, ifosfamide, and cisplatin

A 30-year-old white female was diagnosed with gestational trophoblastic disease in 1981. Despite an original World Health Organization score of 4 and initial aggressive combination chemotherapy, she was treated over a 9-year period with multiple chemotherapy agents and had undergone several operative procedures to remove metastatic lesions for persistent disease. Long-term remission has now been obtained after four courses of etoposide, ifosfamide, and cisplatin.

Retroperitoneal dissemination of cervix cancer following surgical staging

Retroperitoneal and cutaneous dissemination of cervical carcinoma occurred following an extraperitoneal surgical staging procedure. This type of event may be rare or merely underreported in surgical staging literature. Extraperitoneal and laparoscopic staging procedures that result in piecemeal removal of tissue should be studied for the incidence of this type of recurrence.

Phase II trial of menogaril in patients with squamous carcinoma of the cervix: a Gynecologic Oncology Group study

A phase II trial of 200 mg/m2 menogaril was conducted by the Gynecologic Oncology Group (GOG) in women with advanced or recurrent squamous carcinoma of the cervix who had received no previous chemotherapy. Twenty-three patients were placed on the study; 22 are evaluable for toxicity and for response. One patient had incomplete data and was inevaluable. Nine patients (40.9%) had previously undergone surgery, and 21 (95.5%) had received radiotherapy before this trial. GOG grade 3 granulocytopenia occurred in 1 patient (4.5%) but none developed grade 3 or 4 thrombocytopenia. One patient (4.5%) had grade 3 gastrointestinal toxicity. Neither complete nor partial responses were observed in this trial, although 9 patients (40.9%) had stable disease lasting 2 months or more. Menogaril at this dose and schedule is inactive in advanced or recurrent squamous carcinoma of the cervix.

Large loop excision of the transformation zone (LLETZ): a pathologic evaluation

Forty-six LLETZ cone biopsies were performed at the Medical College of Georgia from January 1991 through December 1991. All LLETZ cones were performed for diagnostic reasons following colposcopic biopsies. The majority of procedures were done by residents in obstetrics and gynecology with direct faculty supervision. All specimens were critically evaluated by one pathologist with regard to specimen orientation, thermal artifact, margins, histologic diagnosis, and overall specimen adequacy. The median number of specimens obtained per patient was two, with a maximum of eight. Sixteen patients had a separate endocervical specimen obtained. Thermal artifact was graded as slight in 16 cases, moderate in 18 cases, and severe in 12 cases. The transformation zone was identified in 33 cases. Margins were positive in 17 cases, negative in 21 cases, and nonevaluable in 8 cases. Only 13 LLETZ specimens were believed to compare in quality to a cold-knife cone biopsy. The main criticism about the specimens was the effect of thermal artifact on critical histologic evaluation. In three cases, the thermal artifact precluded an accurate enough evaluation to rule out microinvasion. Mucosa missing at the margins or inadequate representation of the transformation zone were major reasons to call a specimen inadequate. Endocervical specimens suffered the most thermal injury. Orientation of fragmented cone specimens present a problem in histologic evaluation. A major emphasis needs to be placed on the proper indications for LLETZ cone biopsy as well as education of practitioners and pathologists in proper specimen handling.

Paraaortic lymph node sampling by means of an extraperitoneal approach with a supraumbilical transverse "sunrise" incision

OBJECTIVES

Extraperitoneal approaches to removal of lymph nodes for staging in cervical cancer patients are numerous, and each has disadvantages. We developed a supraumbilical transverse incision to initiate irradiation within days of cervical cancer staging.

STUDY DESIGN

Twenty patients with advanced stage IIB or IIIB cervical cancer underwent surgical staging with a supraumbilical incision during the time period Jan. 1, 1988, to Aug. 1, 1992. The incisions were made 6 cm above the umbilicus and carried laterally in a caudad manner to the iliac crests. All nodes were removed in an extraperitoneal fashion.

RESULTS

In the 20 patients who were operated on, the mean number of nodes removed was 9.8. Estimated blood loss ranged from 50 to 300 ml. The procedure time ranged from 50 to 150 minutes. All patients but two had irradiation initiated within 2 weeks of the procedure. Complications included an identified and repaired ureteral injury, a prolonged ileus, and a small bowel obstruction.

CONCLUSIONS

An extraperitoneal approach with the "sunrise" incision allows irradiation to begin within days of surgery. The operating time is relatively short. The incision can be extended caudally and extraperitoneally if needed for removal of bulky pelvic nodes.

The gynecologist and multiple organ failure syndrome (MOFS)

Multiple organ failure syndrome (MOFS) has been alluded to since the early 1940s. It was recognized as a progressive failure to organs in the mid 1970s. Mortality from this syndrome increases proportionally, as the number of failed organs increases. Therapies to prevent MOFS and current concepts about treating failures of individual organs will be presented. Data sources were retrieved from critical care and surgical literature using MEDLINE from 1966 to the present. Searches were confined to English. Several promoters of MOFS are related to the care of gynecologic patients, especially sepsis and hemorrhage. Treatment strategies, especially those related to pulmonary, gastrointestinal, renal, cardiovascular, and nutritional aspects are discussed. Outcome and prognosis may be affected if recognition and therapeutic intervention are initiated early in the clinical course. The ability to prognosticate outcome is related to the number of organs involved. Gynecologists should have clear knowledge of the prognosis of progressive organ failure in order to appropriately counsel the patient and her family.

Metastatic clear-cell hidradenocarcinoma of the vulva

Clear-cell hidradenocarcinoma is a malignant tumor of sweat gland origin. It is most often found on the trunk, head, and extremities. This case report describes a rare occurrence of this tumor on the vulva of a young woman. The discovery of metastatic disease reflects the potentially aggressive nature of this tumor.

Patterns of failure of bulky-barrel carcinomas of the cervix

OBJECTIVE(S)

This retrospective study was conducted to analyze the hypothesis that radiation therapy followed by extrafascial hysterectomy would improve survival in patients with bulky-barrel cervical carcinomas.

STUDY DESIGN

Forty-three patients with bulky-barrel carcinomas of the cervix were treated over a 14-year period. The majority of these were treated with approximately 4000 cGY external beam, followed by brachytherapy, followed by extrafascial hysterectomy.

RESULTS

Forty-seven percent of all patients are dead of disease; 2.3% are alive with disease. Of the total patients, 35% had diseased paraaortic nodes, and 80% of these are dead of disease. Of the patients dead of disease, 80% had distant metastases. Delayed complications included: vesicovaginal fistulas (n = 3), surgery for bowel obstruction (n = 3), rectovaginal fistula (n = 1), and vaginal vault necrosis (n = 3).

CONCLUSION

These data do not support an improvement in survival of patients with bulky-barrel-shaped lesions treated with irradiation plus adjunctive hysterectomy.

Cytology and DNA flow cytometry of peritoneal washings in gynecologic patients

Peritoneal washing cytology, widely used in the management of gynecologic malignancy, entails several difficulties in interpretation. Quantitative DNA analysis by flow cytometry (FCM) holds promise as a more objective method fo diagnosis of malignancy. We performed traditional cytologic examination and single-parameter FCM DNA analysis on peritoneal washings from 136 gynecologic laparotomies, compared these results with the final pathologic findings, and analyzed sources of error. A total of 50 laparotomies were performed for benign disease. Another 86 were performed for cervical, endometrial, and ovarian carcinomas and various other cancers. In the benign group, cytology had one false suspicious but no false positive results, and FCM showed only diploid cells. In the cancer cases, cytology had five suspicious and 13 positive results and one false negative from laboratory error. On review, 16 washings contained confirmed cancer cells. FCM, performed in 13 of these cases, was diploid in 10 and aneuploid in only 3. In six of the diploid cases, visual cell counts showed that tumor cells were present in concentrations of 2.5% or less of total cells. In the remaining four diploid cases, a second DNA determination was obtained by FCM of nuclei retrieved from paraffin blocks of the tumors. These nuclei were diploid by FCM in three of the tumors and aneuploid in only one. Single-parameter DNA FCM was too insensitive to be helpful in our material.

Thrombotic thrombocytopenic purpura first seen as massive vaginal necrosis

Thrombotic thrombocytopenic purpura is a hematologic disorder that affects the microcirculation. A 38-year-old woman was first seen with fever, thrombocytopenia, and vaginal bleeding. Pelvic examination revealed massive vaginal necrosis. Hematology consultation resulted in agreement with the diagnosis of thrombotic thrombocytopenic purpura. This is the first reported case of thrombotic thrombocytopenic purpura first seen as vaginal necrosis of which we are aware.

Massive transfusion: a current review

The use of blood products has come under closer scrutiny over the past decade because of the autoimmune deficiency syndrome. Newer technology has led to the use of component therapy in most situations. The use of fresh-frozen plasma has been overstated in the older literature, and fresh-frozen plasma should be used in specifically indicated situations. On the other hand platelets and fibrinogen (via cyroprecipitate) may be underutilized in patients undergoing massive transfusions. The modern clinician must have a keen awareness of the indications of various transfusion modalities so that patients will receive the maximum benefit with minimal risk.

Evaluating cervical cone biopsy specimens with frozen sections at hysterectomy

Frozen section evaluations of cervical cone biopsy specimens were performed at the time of hysterectomy to exclude invasive cervical cancer. During a two-year period we prospectively evaluated 43 cone biopsy specimens. We found all the diagnoses made with frozen sections to be accurate when compared with prospective permanent sections, and all patients received appropriate therapy. Thirty-eight cases showed no evidence of invasion. Two patients had invasive squamous cell cervical cancer, one had invasive cervical adenocarcinoma extending to the endometrial cavity, and two had microinvasion. All invasive cancers were diagnosed correctly with frozen sections and confirmed with permanent sections. When hysterectomy immediately followed conization, no complications occurred, and no significant increase in blood loss was noted. We found frozen section evaluation of a cone biopsy specimen at the time of hysterectomy to be a reliable procedure that saves time, eliminates the risk of additional anesthesia and decreases patients' costs.

Primary mass closure of midline incisions with a continuous polyglyconate monofilament absorbable suture

Mass closure of midline incisions with a running large-bore permanent monofilament polypropylene suture has been used in general surgery and gynecology patients with a reported small incidence of fascial dehiscence. Late-occurring wound sinus formation is one problem reported with the use of this permanent suture material. Over a 22-month period, 285 patients had midline incisions closed with a continuous, running no. 1 polyglyconate monofilament delayed absorbable suture. Closely spaced bites (about 1.5 cm apart) were taken and placed 2 cm lateral to the fascial edge. Over 60% of the patients had surgery because of gynecologic cancer. Other high-risk factors included obesity in 62%, diabetes in 19%, and previous irradiation or chemotherapy in 22%. An ovarian cancer staging procedure was done in 16% of the patients. Of the remaining patients, almost half had extensive operative procedures that ranged from exenterations to hysterectomies with lymph node dissection. Wound complications were noted in nine patients (3.2%). Seven had superficial infections, one had an evisceration, and one developed a ventral hernia. Wound sinuses did not occur. The closure technique is safe and expedient and distributes tension equally over a continuous line. It has the additional advantage of eventual absorption of the suture material, thereby avoiding the wound sinus problems occasionally reported with large-bore permanent sutures.

Assessment of epidermal growth factor in the healing process of clean full-thickness skin wounds

Epidermal growth factor is a potent stimulant of epithelialization. However, the usefulness of topical applications of epidermal growth factor in accelerating wound healing in full-thickness skin wounds with a large panniculus adiposus has not been clear. Four full-thickness skin incisions were made in the back of 10 female pigs that treated twice a day for 14 days with 2 ml of epidermal growth factor (300 ng/ml) or 2 ml of Ringer's lactate solution in a single-blind, randomized fashion. Two pigs received only epidermal growth factor, two pigs received only Ringer's lactate solution, and six pigs were treated with both solutions. The original skin plug was weighed to ensure similarity of groups. Photographs and measurements of each incision were taken every 7 days. The mean surface areas of the incisions treated with epidermal growth factor were 8.45, 7.50, and 2.30 cm2; in the incisions treated with Ringer's lactate solution the measurements were 8.42, 8.16, and 2.37 cm2 on observation days 1, 7, and 14, respectively. Although a trend toward a faster healing rate was noted in the incisions treated with epidermal growth factor, this difference was not statistically significant. With the doses and the time interval used between treatments, minimal benefit was obtained with epidermal growth factor when compared with Ringer's lactate solution.

A clinical-pathologic study of mixed müllerian tumors of the uterus over a 16-year period--the Medical College of Georgia experience

From 1972 through 1987, 40 patients at the Medical College of Georgia were assessed with a diagnosis of mixed müllerian tumors which constituted 3.5% of all female genital tract malignancies. The mean patient age was 65.3 years; 60% of the patients had stage I disease. Of those patients with clinical stage I disease, more advanced disease was found at celiotomy in 33%. Retroperitoneal nodes were positive for malignancy in 35% of 20 patients who underwent node sampling. Cell washings were positive in 12%, and 9% had omental metastases. Forty-seven percent had homologous tumors; 53% of tumors were heterologous. Relatively poor prognosis was associated with large tumor volume, vascular invasion, nodal metastases, and disease outside the uterus. The overall survival rate was 32%; 14 of 24 patients with stage I disease are dead of disease. Of patients dead of disease, 92.5% had distant metastases. Adjuvant therapy with a combination of VP-16, cisplatin, and irradiation was beneficial in four high-risk patients.

Pelvic abscess: examination and transvaginal drainage guided by real-time ultrasonography

We have reported a case involving a multiloculated pelvic abscess that was examined, incised, and drained under the guidance of real-time ultrasonography. This method is safe and has certain distinct advantages over more traditional surgical techniques.

Current management of non-squamous carcinoma of the cervix

The incidence of non-squamous carcinoma of the cervix, relative to squamous cell carcinoma, seems to have been increasing over the past 15 years, and adenocarcinomas currently constitute 10 to 18% of cervical cancers. Uncertainties regarding the clinical behavior and management of women with non-squamous cervical cancer persist. Certain cell types and grade of adenocarcinomas play a role in prognosis and treatment selections. Treatment via irradiation or radical surgery for Stage I, small, garden variety cervical adenocarcinomas will result in excellent survival. Conversely, survival may be poor in early stage non-squamous lesions if they are of high grade or of certain cell types, such as adenosquamous carcinoma. Patients with advanced cancers of other organ systems can now achieve an increase in progression-free interval with neoadjuvant chemotherapy or concomitant irradiation/chemotherapy. Such treatments might also benefit patients with non-squamous cervical cancers.

Primary mass closure of midline incisions with a continuous running monofilament suture in gynecologic patients

Over a 42-month period, 210 patients had a lower midline incision, usually extending around the umbilicus, that was closed with a continuous, running number 2 polypropylene suture. Patients in this study had various predisposing factors for wound disruption. Over 60% were operated upon because of gynecologic cancer. Additional high-risk factors included obesity in 56%, diabetes in 28%, previous irradiation or chemotherapy in 17%, and ascites in 8%. The operative procedures performed ranged from hysterectomies with node sampling to bowel resections and exenterations; wound complications were noted in seven patients. One patient had an incisional hernia. No eviscerations occurred. The closure is safe, expedient, and cost-efficient, and distributes tension equally over a continuous line.

Fine-needle aspiration of inguinal lymph nodes in gynecologic practice

Palpable inguinal lymph nodes are a common finding in gynecologic patients. Assessment of such nodes is especially important in the clinical staging of pelvic cancers. To determine the accuracy, safety, and usefulness of fine-needle aspiration in this setting, we retrospectively reviewed pathologic and clinical data from 62 consecutive aspirates of inguinal lymph nodes in 48 gynecologic patients, of whom 42 had cancer. Aspirates from 37 patients yielded diagnostic material. Aspirated tumor cells consistently reflected the primary tumor histology. Tumors included carcinomas of the vulva, vagina, and cervix, and carcinomas and mixed mesodermal cancers of the corpus and ovary. Node excision and clinical observations provided adequate follow-up for 19 positive and 15 negative aspirates, and identified no false positives and two false negatives. The role of fine-needle aspiration varied with the tumor type and stage. It provided the first microscopic diagnosis of cancer in six patients and the first diagnosis of metastasis in six others. Decisions concerning surgery, radiation ports, and chemotherapy frequently depended on the results of fine-needle aspiration. There were no complications from the procedure. Fine-needle aspiration is an accurate, safe, and useful method for assessing clinically suspicious inguinal nodes.

Adenoid cystic carcinoma of the cervix in women under age 40

Adenoid cystic carcinoma of the cervix, traditionally associated with a poor prognosis, occurs in postmenopausal patients in the vast majority of cases reported. Only four cases have been reported in women less than age 40, and none in women less than age 30. Three new cases of adenoid cystic carcinoma of the cervix are reported in women aged 24, 27, and 38 years. All three patients were treated with radical pelvic surgery; lymph node metastases and vascular involvement were prominent. Adjuvant chemotherapy with cisplatin was used in two patients, one of whom has had long-term survival. A review of the literature is also presented.

Epithelial tumors of the ovary in women less than 40 years old

From Jan 1, 1978 through Dec 31, 1983, 64 patients with epithelial ovarian tumors, frankly malignant or borderline, were managed at one institution. Nineteen patients (29.7%) were under age 40. The youngest patient was 19 years old. Nulliparity was present in 32% of this group of patients. Of these young patients, 58% had borderline epithelial tumors, compared to 13% of patients over 40 years of age. Twenty-one percent of the young patients were initially managed by unilateral adnexal surgery. The overall cumulative actuarial survival rate of all young patients was 93%. Young patients with epithelial ovarian tumors tend to have earlier grades of epithelial neoplasms, and survival is better than that reported for older patients with similar tumors.

Hidradenitis suppurativa of the anogenital region: response to isotretinoin

Hidradenitis suppurativa, a chronic relapsing disease of apocrine gland-bearing areas, most frequently occurs in the axillae, groin, perineal, and perianal regions. Hidradenitis of vulva is frequently misdiagnosed and inadequately treated. The case of a 15-year-old nulliparous black female adolescent referred for evaluation of multiple draining fistulas of the anogenital region is presented. Diagnostic studies for granulomatous disease were negative. Results of a barium enema were normal and biopsies were compatible with the diagnosis of hidradenitis suppurativa. She was treated for 22 weeks with isotretinoin, 1 mg/kg daily, with an excellent response. Side effects were minor and included cheilitis, mild xerosis, and a transient elevation of serum alkaline phosphatase levels. Few patients with severe hidradenitis have been responsive to this synthetic vitamin A derivative. A review of the literature indicates that the results of treatment with isotretinoin for hidradenitis have been at best equivocal. Isotretinoin should never be used during pregnancy because of known teratogenic effects. Women of childbearing age must use effective contraception during treatment.

Another look at the second-assessment procedure for ovarian epithelial carcinoma

Over a 10-year period, 65 of 196 patients (33%) with ovarian epithelial malignancy, previously treated with chemotherapy, had a second-look operation if the disease was clinically absent. All procedures were done by one of three gynecologic oncologists, and 48% of the patients had a positive second-look procedure. Of patients with original stage I, II disease, 25% had a positive second-look operation, contrasting with 61% of patients with stage III, IV. Significant perioperative morbidity occurred: one patient had intraoperative vascular collapse; 15% had prolonged ileus; 17% had small bowel resections at the time of the second-look operation or in the postoperative period. Of all patients with negative second-look operations, 24% have had recurrent disease from 5 to 23 months after the procedure. These recurrences were in the liver or distant sites in 63% of the patients. Second-look operations, if still indicated by negative noninvasive techniques, should be performed in tertiary care centers under study situations in a standard fashion.

Hysterography in patients with suspected uterine cancer: radiographic and histologic correlations and clinical implications

The present study correlated the hysterographic and nonradiation-affected uterine histologic findings in 91 patients with suspected uterine cancer. Hysterography helped diagnose correctly a benign or malignant lesion, and helped identify the correct primary site of a malignant lesion in 11 patients. In 65 patients with a final diagnosis of endometrial carcinoma, all five cases of true endocervical involvement were identified, 69% were determined to have either no residual tumor or no myometrial invasion, and 88% were predicted correctly to have a myometrial invasion of greater than one-half. Prediction of the volume, distribution, and point of maximum invasion permitted the uterus to be opened so as to permit the best histologic assessment of the depth and extent of the lesion.

Invasive squamous cell carcinoma of the vagina: a 14-year study

A retrospective review was conducted of patients with squamous cell carcinoma of the vagina managed at one institution over a 14-year period. The 28 cases of squamous cell vaginal carcinoma constituted 3.1% of all female genital tract cancers. Forty-six percent of the patients had undergone a previous hysterectomy for benign disease or for cervical intraepithelial neoplasia; 14.2% had had irradiation. Disease of stage III or greater occurred in 43% of the study group. The majority of patients were treated by radiation therapy. The overall survival was 42.8%. This review indicates that patients who have had a previous hysterectomy should remain under close surveillance.

Solid ovarian teratoma with neuroglial metastases to periaortic lymph nodes and omentum

We have described a 16-year-old girl who had a unilateral adnexectomy for a solid ovarian teratoma, grade 0. Periaortic nodes and omentum contained grade 0 neuroglial metastases.

Cerebellar metastases from epithelial ovarian carcinoma. A case report

Central nervous system metastases are an unusual sequela of epithelial ovarian neoplasms, occurring in less than 1% of reported autopsy cases. A case of cerebellar metastatic disease occurred following combination chemotherapy and a negative second-look operation for a stage III poorly differentiated adenocarcinoma of the ovary. The single metastatic tumor was resectable, and the patient had resolution of her symptoms following surgery. This is the fourth report of an epithelial ovarian carcinoma metastatic to the cerebellum.

Recurrent carcinoma in situ of the vagina following split-thickness skin graft vaginoplasty

A patient who developed squamous cell carcinoma in situ in a split-thickness skin graft neovagina is presented. This is the third reported case in the English literature of a patient previously treated for carcinoma in situ of the vagina who later developed an identical lesion in the graft. Management of this neoplasm is discussed, and follow-up for patients with neovaginas is emphasized.

Computed tomography in evaluation of gynecologic malignancies: a retrospective analysis

The results of preoperative computed tomography and operative findings were assessed retrospectively in 52 patients with cervical, uterine, and ovarian neoplasms. Overall sensitivity and specificity for all disease states was 57% and 79%, respectively. Overall diagnostic accuracy was 69%. The use of computed tomography was felt to be helpful in evaluation of lymphadenopathy due to cervical cancer and in patients with suspected ovarian neoplasms. In uterine neoplasms, however, computed tomography did not add useful information.

Extraperitoneal lymph node dissections with use of a midline incision in patients with female genital cancer

Recent investigations have suggested that extraperitoneal, as compared to transperitoneal, lymph node dissections may result in significantly less morbidity in patients who later have external beam irradiation. Some incisions designed to perform such dissections do not afford easy access to the opposite side. With use of a midline incision carried down to the preperitoneal space, 30 patients underwent bilateral pelvic lymph node dissections. When necessary, access to the para-aortic nodes by an extraperitoneal approach was accomplished by use of a modification of this midline incision. Operating time to complete the pelvic dissection ranged from 35 to 90 minutes. The mean estimated blood loss for the dissection was 135 ml. The advantages of this extraperitoneal approach include easy access to lymph nodes on either side, ability to use the peritoneum as a pack, and an easier access to the obturator space nodes.

Retroperitoneal hematoma: an unusual complication of cold knife conization of the cervix

A case of an unusual complication of cold knife conization and associated extensive retroperitoneal hematoma is presented. The contributing factors, prevention, and management of this complication are discussed.

Cytosol estrogen receptor content of female parietal peritoneum

The ovarian and peritoneal mesothelium are believed to derive from the same embryonal coelomic epithelium. Neoplastic proliferation of these epithelia is sometimes grossly and histologically similar. Recently estrogen receptors have been identified in gynecologic neoplasms. With the use of standard techniques, the parietal peritoneum was assessed for estrogen receptor content in 17 women undergoing celiotomy for various reasons. All peritoneal specimens were negative for estrogen receptor content. This suggests a heterogeneous origin of the peritoneal surface epithelium and that peritoneum may not be müllerian in origin.

Clinical findings and ancillary studies on identical twins exposed to diethylstilbestrol in utero. A case report

Diethylstilbestrol (DES) exposure in utero in twin gestations has been reported on infrequently. In this case, both twins had colposcopically proven and biopsy-proven evidence of cervical adenosis. Infertility was discordant.