Cynthia Angel

Distribution of disease at autopsy in 100 women with ovarian cancer

Clinical and morphologic factors that affected the distribution of disease are described in 100 cases of ovarian cancer at autopsy. In addition to the expected pattern of pelvic and abdominal peritoneal spread, extensive visceral parenchymal metastases were seen: liver parenchyma (45%), lung parenchyma (39%), small and large intestinal wall (52% and 55%), lymph nodes (70%), pancreas (21%), ureter (24%), bone (11%), and brain (6%). Liver parenchymal metastases replaced more than one third of the liver in 25% of cases, whereas lung metastases always involved less than one third of the lungs. When intestinal wall invasion was seen, bowel obstruction was present more often (71%) than when only intestinal serosa was involved (30%). Lymphatic invasion was predictive of lymph node, small intestinal wall, pancreatic, and liver as well as lung parenchymal metastases. Blood vessel invasion was predictive of pancreatic and ureteral metastases. Clinical stage I at diagnosis was associated with high incidences of liver parenchymal (56%), lymph node (56%), lung parenchymal (44%), large intestinal wall (33%), and bone (33%) metastases. Thus, ovarian cancer has parenchymal metastases similar to other carcinomas in addition to its peritoneal spread. Lymphatic and blood vessel invasion is predictive of such involvement. Intestinal wall invasion predicts bowel obstruction.

Morbidity and recurrence with modifications of radical vulvectomy and groin dissection

Vulvar carcinoma has been managed in recent years with modifications of radical vulvectomy and groin dissection. Separate groin incisions, superficial inguinal lymphadenectomy, unilateral groin dissection, and wide excision have been utilized to reduce the morbidity of treatment. In this study, the surgical management of 82 patients with vulvar squamous cell carcinoma was reviewed in order to assess morbidity and risk of recurrence. A modification of radical vulvectomy and groin dissection was employed in 67 patients, while 15 patients underwent classical en-bloc vulvar and groin dissection. Wound complications of the vulva occurred in 1 of 12 patients undergoing hemivulvectomy, in 8 of 55 undergoing radical vulvectomy, and in 7 of 15 who had en-bloc vulvar resection and groin dissection (P = 0.01). Among the 46 patients undergoing bilateral groin dissection through separate incisions, groin breakdown, lymphocyst, and lymphedema occurred in 10 (22%), 7 (15%), and 7 (15%), versus 0, 1 (7%), and 2 (13%) of the 15 who had unilateral groin dissection. Modification of vulvar resection did not increase the risk of local recurrence. Groin recurrence developed in 2 of 15 patients who underwent en-bloc groin dissection and in 1 of 46 who underwent bilateral groin dissection through separate incisions. Two of 15 who had a unilateral groin dissection recurred in the contralateral groin. The risk of recurrence as well as morbidity following modifications of radical vulvectomy with groin dissection should be considered when planning treatment.

Use of thin‐layer preparations for gynecologic smears with emphasis on the cytomorphology of high‐grade intraepithelial lesions and carcinomas

Thin‐layer (TL) technology can improve the detection rate for squamous lesions of the uterine cervix. Studies to date have under‐represented high grade lesions and malignancies. The present study utilized a patient population at high risk for such lesions in order to analyze the performance of TL procedures in this group, and in addition, to assess the similarities and differences in morphologic appearances of specimens prepared by the two methods.

Survival time, causes of death, and tumor/treatment-related morbidity in 100 women with ovarian cancer

One hundred cases of ovarian cancer were studied at autopsy to determine the effect of morphologic and clinical factors on survival time, the primary cause of death, and tumor/treatment-related morbidity. The mean survival time was 19 months (0 to 174 months). Increasing neoplastic histologic grade and increasing clinical stage at diagnosis were each associated with decreased survival time. In grade I tumors, the mean survival time was 84 months; in grade II tumors, it was 18 months; and in grade III tumors, it was 12 months (P = .0008). Patients who presented in stage I or II had a better survival time (28 months) than those who presented in stage III or IV (15 months) (P = .02). The most common causes of death were disseminated carcinomatosis (48%), infection (17%), pulmonary embolus (8%), and combinations of infection and carcinomatosis (11%). In patients dying of infection, 43% had sepsis, 21% had pneumonia, and 25% had a combination of sepsis and pneumonia. Escherichia coli and Klebsiella were the most common pathogens identified postmortem. Intestinal obstruction (51%) and ureteral obstruction (28%) were the most common forms of tumor-induced morbidity. Bone marrow depression and resultant pancytopenia was the most common form of treatment-induced morbidity.

Computed tomography of leiomyomatosis peritonealis disseminata with malignant transformation

Malignant transformation of leiomyomatosis peritonealis disseminata is a very rare occurrence, reported twice previously. We report the third case and present the computed tomography findings associated with the development of this unusual pathologic condition.

Clinical presentation and management of stage I cervical adenocarcinoma: A 25 year experience

In this study, we review the clinical presentation, treatment, and prognosis of 89 patients with stage I cervical adenocarcinoma treated at Strong Memorial Hospital over the past 25 years. In the past decade, the mean age of patients with stage I cervical adenocarcinoma was 44 years, in contrast to a mean of 58 years in the prior interval (P less than 0.001). Prior to 1980 only 4% of patients were of childbearing age, whereas in the past decade 27% were under 35 years old (P = 0.02). The difference in age at presentation cannot be explained by earlier detection, as the fraction of stage I patients, the mean tumor size, and the percentage of clinically occult tumors have not changed. There were no ovarian metastases in 41 patients who underwent oophorectomy. Adenosquamous tumours did not differ in prognosis from pure adenocarcinoma. Grade and lymph node status were significant predictors of outcome. Treatment results have not improved over the past 25 years, and combined therapy with radiation and surgery offered no advantage over radiation alone. Because this tumor is more frequently seen in younger patients, the management of occult adenocarcinoma with early stromal invasion has become problematic. Ovarian conservation has been questioned, and the lack of generally accepted criteria for microinvasive adenocarcinoma has led to radical therapy in patients who might have been adequately treated with local excision. Further study is necessary to guide our recommendations regarding preservation of ovarian function or even childbearing potential in young women.

Reconstruction of an extensive vulvectomy defect using the gluteus maximus fasciocutaneous V-Y advancement flap.

Effective management of a vulvar wound resulting from oncological ablative surgery poses a formidable task for the reconstructive surgeon. During the past two decades, numerous procedures have been described in an effort to provide stable, sensate coverage that minimizes deformity and preserves function, often in the setting of concomitant radiation. At the authors’ institution, a fasciocutaneous V-Y advancement flap based on the gluteus maximus has been adopted as a common approach to this problem. They present their institutional experience with this procedure. A 10-year chart review (1991–2001) yielded a series of 20 vulvectomy patients, all of whom were reconstructed by the same surgeon using ischial fasciocutaneous V-Y flaps based on perforators from the inferior border of the gluteus maximus muscle. Patients underwent vulvectomy for recurrent or advance-stage vulvar cancer, or extensive carcinoma in situ. Squamous cell carcinoma was the most common pathology (N = 13). Fifteen patients had bilateral V-Y flaps; the remainder had unilateral procedures. Six patients underwent prior radiation therapy. Two patients had delayed reconstruction for vaginal stenosis. Flap survival was 100%. There were no major complications, early or late. Minor complications were limited to localized areas of delayed healing, all of which responded to conservative measures. Functional outcome was excellent in all patients. At an average follow-up of 44 months, there were five episodes of recurrent disease necessitating surgical intervention. Based on this series, the gluteus maximus V-Y advancement flap provides a straightforward and reliable method to recruit local tissue for stable coverage of these often difficult-to-manage wounds.

Comparison of transabdominal and endovaginal sonographic approaches in the diagnosis of a case of cervical pregnancy successfully treated with methotrexate

Cervical pregnancy occurs in approximately 1 in 16,000 pregnancies. The majority of these cases left untreated will abort spontaneously in the first trimester, apparently because of the unfavorable implantation site. The incidence of cervical pregnancies is rising and may reflect the steady increase in ectopic gestations and cesarean sections. 2 In the past, this diagnosis was made late in the first trimester, usually following heavy vag·inal bleeding (many times leading to emergency hys· terectomy). Currently, the diagnosis is based on ultrasound findings, permitting efforts at conservative treatment. We compare the transabdominal and endovaginal modes of sonography in a case of cervical pregnancy that was subsequently treated with metho· trexate.

Unusual endovaginal ultrasonography and magnetic resonance imaging of placental site trophoblastic tumor.

Previous reports of ultrasonographic and magnetic resonance imaging of placental site trophoblastic tumor have described a cystic appearance of this rare disease. We present the first case in which endovaginal ultrasonography and magnetic resonance imaging revealed a solid intramural mass.

Endometrial cancer: the potential role of cervical cytology in current surgical staging

OBJECTIVE To evaluate cervical cytology, tumor grade from endometrial sampling, and myometrial invasion with the risk of nodal spread in endometrial cancer. METHODS Cervical cytology was obtained in 300 patients with endometrial cancer before surgical staging, which included lymphadenectomy. Tumor grade and histology from endometrial sampling were compared with final pathology, and the risk of nodal spread in relation to cervical cytology, tumor grade, and myometrial invasion was assessed using χ2 and logistic regression analysis. RESULTS Endometrial cells on cervical cytology, deep myometrial invasion, and high-grade tumor were associated with 91%, 87%, and 83% of the cases with nodal spread, respectively. In patients with grade 1 tumor on biopsy, final pathology revealed grade 2 in 21%, and grade 3 in 2%. In patients with normal cervical cytology, no nodal metastases occurred with grade 1 tumor on biopsy, and no aortic metastases occurred, regardless of grade. Cervical cytology and tumor grade contributed independently to the likelihood of nodal metastases. CONCLUSION All patients with endometrial cancer should undergo lymphadenectomy until a reliable system is found to identify those with negligible (less than 1%) risk of nodal spread. The risk of lymph node spread in those with normal cervical cytology is low (2%). Further study of those with normal cervical cytology is needed to determine if lymphadenectomy can be omitted with grade 1 tumor on biopsy, or whether aortic lymphadenectomy is necessary regardless of grade.