Danny Barnhill

Clinical-pathologic study of stage IIB, III, and IVA carcinoma of the cervix : extended diagnostic evaluation for paraaortic node metastasis : a gynecologic oncology group study*

Three hundred twenty patients were entered into GOG Protocol 63, a clinical-pathologic study of stage IIB, III, and IVA cervical carcinoma. Following the completion of FIGO staging prerequisites, patients had computerized tomography (CT), a lymph-angiogram (LAG), and an ultrasound (US) of the aortic area. If any study was positive, a cytologic or histologic evaluation by fine-needle aspiration or selective paraaortic lymphadenectomy was performed. Paraaortic node dissection was mandated for patients with negative extended staging studies. Results of extended staging evaluations were compared with histologic or cytologic results. Two hundred sixty-four patients were eligible and evaluable. One hundred sixty-seven patients (63%) were stage IIB, 89 (34%) were stage III, and 8 (3%) were stage IVA. Positive paraaortic nodes occurred in 21% of stage IIB, 31% of stage III, and 13% of stage IVA. LAG sensitivity was 79% with a specificity of 73%. Sensitivity of CT and US was 34 and 19%, respectively, with specificities of 96 and 99%, respectively. The frequency of false-negative results with LAG for patients with stage IIB disease was 6%. This decrease is consistent with a stable sensitivity and specificity. These findings suggest that a negative LAG may be adequate to eliminate surgical staging in subgroups with low risk of metastasis to the aortic nodes. Until new noninvasive testing methods are developed, LAG appears to be the most reliable noninvasive examination to evaluate spread of cervical cancer to aortic nodes.

Cervical carcinoma found incidentally in a uterus removed for benign indications.

Thirty-five patients with invasive cervical carcinoma discovered in a uterus removed for benign indications were evaluated and treated from 1961 through 1983. Although formal staging was not possible, patients with presumed stage IA disease had a 100% five-year survival rate regardless of the addition of adjuvant therapy. All patients with more advanced disease received radiation therapy. Patients with presumed stage IB disease had a corrected five-year survival rate of 78%, and those with presumed stage IIB disease had a corrected five-year survival rate of 67%. No patient in this series was thought to have disease more advanced than a stage IIB equivalent. The hysterectomy alone may have been adequate therapy for patients with presumed stage IA disease. Adjuvant radiation therapy appears to be effective treatment for patients with presumed stage IB or IIB disease.

Vulvar dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans of the vulva is an extremely rare neoplasm. This low-grade sarcoma of the dermis clinically appears to be encapsulated but microscopically has tumor projections well away from the central nodules. Wide local excision is the recommended treatment for dermatofibrosarcoma protuberans; however, a more radical surgical approach may be needed to obtain clear surgical margins. The following case study present the fifth reported patient with this unusual neoplasm on the vulva.

A technique for managing terminally III ovarian carcinoma patients

A patient with terminal ovarian carcinoma was admitted with malnutrition, abdominopelvic pain, and an inoperable complete small bowel obstruction after failing standard therapy and several experimental regimens for her disease. Despite this serious situation, she had an overall high performance status. Instead of administering intravenous narcotics, providing nasogastric suction, and giving other supportive care to make her apparently imminent death as comfortable as possible, her malnutrition was treated with total parenteral nutrition administered through an indwelling central venous catheter during the night hours only. The pain was successfully treated with an indwelling epidural catheter with the continuous infusion of morphine through a portable pump carried by a shoulder strap. The intestinal obstruction was relieved by a percutaneous endogastric tube which drained spontaneously into a leg bag. This regimen allowed the patient complete daytime mobility. She remained active, largely at home, with slowly progressing tumor until her death 9 months after the institution of this supportive care.

Ovarian mucinous cystadenocarcinoma of low malignant potential associated with a mature cystic teratoma

A 54-year-old female underwent exploratory laparotomy for evaluation of a large abdominopelvic mass. She was found to have a 29-pound multicystic tumor arising from the right ovary. There were no other gross intraabdominal abnormalities. Histologic examination of the mass revealed a mucinous cystadenocarcinoma of low malignant potential and a mature cystic teratoma. To our knowledge, this is the first case report of an ovarian epithelial adenocarcinoma of low malignant potential associated with a mature cystic teratoma.

Metastatic placental site trophoblastic tumor

A patient with metastatic placental site trophoblastic tumor is presented. Her treatment included several aggressive chemotherapeutic regimens. In this patient, the clinical course and assays of beta-hCG (beta fragment of human chorionic gonadotropin) correlated with her response to these treatments.

Methotrexate-induced erythema multiforme

The folic acid antagonist, methotrexate, has many applications in the treatment of neoplastic disease. While methotrexate produces several well-recognized toxic effects, cutaneous reactions are rare. A patient who developed classical erythema multiforme while receiving low-dose methotrexate as treatment of nonmetastatic gestational trophoblastic neoplasia is presented. Erythema multiforme has been associated with a variety of pharmacologic agents. It typically presents as a pruritic papular dermatitis of the extensor surfaces of the extremities and may require multiple skin biopsies to establish the diagnosis. Spontaneous reversal usually occurs with discontinuation of therapy. Patients developing erythema multiforme related to antineoplastic agents should be switched to an alternate regimen.

Nongenital pelvic leiomyosarcoma metastatic to the heart.

A patient who had a 5-year history of a low-grade nongenital pelvic leiomyosarcoma was evaluated for worsening dyspnea, hypertension, and jugular venous distension. An echocardiogram revealed a large right atrial mass. At surgical exploration, metastatic leiomyosarcoma was found within the inferior vena cava extending from below the renal veins up into the right atrium. Using cardiopulmonary bypass with profound hypothermia and circulatory arrest, the inferior vena cava was opened below the renal veins, and the tumor was transected. That portion of the tumor above this transection was then extracted through a right atriotomy. Resection of the pelvic tumor was not thought to be feasible. The patient remains asymptomatic with stable pelvic tumor 1 year after the procedure.

Bowel perforation associated with intraperitoneal chromic phosphate instillation

Intraperitoneal chromic phosphate is widely used as adjuvant therapy in the treatment of early-stage ovarian epithelial carcinoma. Delayed bowel injury is an infrequently observed complication of chromic phosphate administration. This report presents a case of colon perforation which occurred 4 months after treatment with intraperitoneal chromic phosphate for stage IB ovarian papillary serous cystadenocarcinoma.