David C. Figge

Adenocarcinoma of the uterine cervix

Abstract Adenocarcinoma of the cervix represented 12.7% of all cervical carcinomas seen at the University of Washington. The mean age of 66 patients with adenocarinoma of the cervix was not significantly different from the mean age of those with squamous cell carcinoma and was 43.6 (range 15–83). Seventy-six percent of the patients were assigned to Stage I disease. Stage II disease was diagnosed in 15% and Stages III–IV represented 9%. The pathologic diagnosis included adenocarcinoma in 50 patients, adenosquamous carcinoma in 9, clear cell carcinoma in 5, and adenoid cystic carcinoma in 2. The survival rate was directly related to the stage of disease and to the presence or absence of lymph node metastasis. The recurrence rate was significantly higher in adenocarcinoma of the cervix with node metastasis when compared with a similar group of patients with squamous cell carcinoma.

Adenocarcinoma of the uterine tube: Potential for lymph node metastases

A clinicopathologic study of 15 cases of primary adenocarcinoma of the uterine tube occurring over a 12-year period is presented. The mean age of the patients was 54.8 years. Predominant symptoms were abnormal bleeding, abnormal vaginal discharge, and pelvic pain. Abnormal vaginal cytology was noted in two instances (13%). A pelvis mass was detected in two thirds of patients. The neoplasm was bilateral in three instances (20%). Lymph nodes were involved in eight cases (53%), and metastatic spread to the para-aortic nodes was present in five (33%). The most common primary treatment was total abdominal hysterectomy and bilateral salpingo-oophorectomy. Various combinations of adjuvant radiation therapy and chemotherapy were also employed. Six patients (40%) are alive without evidence of recurrent cancer. It is concluded that lymphatic spread, especially to the para-aortic nodes, is a major pattern of disseminaton for adenocarcinoma of the uterine tube. The presence of tumor in capillary-like spaces bears a strong relationship to lymph node metastases, and the para-aortic nodes are a frequent site of involvement even when the disease is apparently limited to the tube.

Uterine smooth-muscle tumors of uncertain malignant potential.

Objective: To determine whether tumors meeting the criteria of Hendrickson and Kempson for uterine smooth‐muscle tumors of uncertain malignant potential have a natural history different from those of leiomyomas and leiomyosarcomas. Methods: Tumors with five to ten mitoses per ten high‐power fields and with mild or moderate cellular atypia were classified as tumors of uncertain malignant potential. Tumors with two to four mitoses per ten high‐power fields and severe cellular atypia would also be classified as tumors of uncertain malignant potential, but we had no tumors that fell into this latter group. Forty‐seven women with leiomyosarcoma or smooth‐muscle tumors of uncertain malignant potential were identified. Paraffin‐embedded blocks were recut, and hematoxylin and eosin‐stained sections were studied for mitotic counts and cellular atypia. Statistical analysis used X2, Fisher exact test, Student t test, and Kaplan‐Meier life table analysis. Results: Fifteen tumors were classified as uncertain malignant potential and 32 as leiomyosarcomas. The patients with leiomyosarcoma were significantly older and more likely to present with extrauterine disease. Those with tumors of uncertain malignant potential had a 5‐year disease‐free survival of 66% and overall survival of 92%, compared to 28 and 40%, respectively, for leiomyosarcomas; these differences were statistically significant. Patients with tumors of uncertain malignant potential tended to have a protracted clinical course after development of recurrence, and several survived longer than 5 years with metastatic disease. Conclusions: Patients with five to ten mitoses per ten high‐power fields and mild to moderate cellular atypia had a prognosis significantly better than that of patients with leiomyosarcomas. In this group, only 27% developed a recurrence, and after recurrence they tended to have a protracted course. Some of these tumors do have a very aggressive course, and the term “uncertain malignant potential” is appropriate. (Obstet Gynecol 1994;83:1015‐20)

Fetal and maternal considerations in the management of stage I-B cervical cancer during pregnancy.

Abstract The timing of treatment for stage I-B cervical carcinoma diagnosed during pregnancy is complicated by conflicting concerns for fetal survival and control of malignancy. There were 11 pregnant women with stage I-B cervical carcinoma diagnosed prior to fetal viability since 1969. Six patients were managed with termination of pregnancy and radical hysterectomy with pelvic lymphadenectomy. In 5 patients, treatment was delayed for 6 to 17 weeks and then delivery was accomplished by cesarean section followed directly by radical hysterectomy and pelvic lymphadenectomy. Two of the infants experienced complicated neonatal courses and would have benefited from additional delay. Benefits that could be achieved by delaying delivery for the fetus were calculated from a review of 600 inborn infants without congenital anomalies admitted to the neonatal intensive care (NICU) during 1984 and 1985. Neonatal mortality decreased from 32.8% at 26–27 weeks to 2.7% at 34–35 weeks gestation. Similar improvements in neonatal morbidity were demonstrated. Although adverse maternal outcomes were not associated with delay, an evaluation of risk cannot be derived from this series. Significant fetal benefit can accrue from relatively short delays in planned delivery dates. When stage I-B cervical carcinoma is diagnosed during pregnancy and when fetal survival is desired, delivery should be delayed to achieve fetal maturity, rather than only potential viability.

Adjuvant postoperative pelvic radiation for carcinoma of the uterine cervix: pattern of cancer recurrence in patients undergoing elective radiation following radical hysterectomy and pelvic lymphadenectomy

Thirty-seven patients with invasive cervical cancer have been referred to the Department of Radiation Oncology at the University of Washington following radical hysterectomy and pelvic lymphadenectomy. Patients at high-risk for tumor recurrence were selected for adjuvant pelvic irradiation because of adverse risk factors identified on pathological study of the hysterectomy specimen. All patients were treated because of possible residual, microscopic carcinoma. Fourteen patients (38%) developed recurrent cancer, of whom 10 (27%) manifested initial failure within the irradiated volume. Possible explanations for this observation are discussed.

Patterns of recurrence of carcinoma following radical hysterectomy

One hundred eighty-six radical abdominal hysterectomies are reviewed. Twenty-two instances of clinically recurrent carcinoma following operation were encountered over a 18-year period. In review of these cases it is apparent that patients with adenocarcinoma or adenocystic carcinoma have an increased likelihood of positive lymph node metastases or lymphatic-vascular invasion at the time of surgery. If this occurs, there is an increased probability of recurrent disease. Poor differentiation of the tumor, bulky disease, deep infiltration of tumor, involvement of capillary-like spaces, and lymph node metastases all appear to represent poor prognostic indices in patients operated upon. Patients with adenocarcinoma generally have a longer disease-free interval before recurrence than patients with squamous carcinoma. Postoperative radiation therapy following radical surgery appears to increase significantly the disease-free interval until recurrence and influences the site of recurrent disease but has no demonstrable effect on ultimate survival.

The use of intraoperative radiation therapy in radical salvage for recurrent cervical cancer: Outcome and toxicity

OBJECTIVE Our purpose was to evaluate the contribution of intraoperative radiation therapy in the management of recurrent cervical cancer. STUDY DESIGN Twenty-two patients were treated with electron beam intraoperative radiation therapy for recurrent cervical cancers that were confined to the pelvis but were too extensive to be adequately treated by radical surgery alone. All patients underwent extensive surgical dissection for exposure and maximal tumor resection. Doses of intraoperative radiation therapy ranged from 14 to 27.8 Gy (median 22 Gy). Twelve patients received intraoperative radiation therapy to address gross residual disease, and 10 patients were treated for microscopically positive or close surgical margins. RESULTS The five-year disease-specific survival and local control rates were 43% and 48%, respectively. There were trends toward better local control and disease-specific survival in patients with microscopic residual disease compared with those with gross residual disease. Seven patients had peripheral neuropathy related to treatment, and four of these cases resolved. CONCLUSION In carefully selected cases intraoperative radiation therapy contributes to radical salvage of patients with recurrent cervical cancer involving the pelvic wall.

Paclitaxel (Taxol) treatment for refractory ovarian cancer: Phase II clinical trial

OBJECTIVE Our aim was to determine the efficacy and toxicity of paclitaxel in the treatment of refractory and platinum-resistant epithelial ovarian cancer. STUDY DESIGN Eligibility required three prior failed chemotherapy regimens and documented platinum resistance. One hundred patients with advanced ovarian cancer received paclitaxel 135 mg/m2 over 24 hours every 21 days with optional granulocyte colony-stimulating factor support. RESULTS Paclitaxel was generally well tolerated. In four patients bowel perforation or fistula developed. After three cycles 34% of patients had stable disease and 25% of patients demonstrated a response, either partial or complete. After six cycles 24% of patients continued to respond. To date, six patients have achieved a complete response. CONCLUSION A 25% response rate in patients with refractory ovarian cancer was observed, which was durable to six cycles.

Cervical cancer after initial negative and atypical vaginal cytology

Abstract Increasing concern has been expressed over the likelihood of the failure of vaginal cytology to detect existent cervical cancer. A review of 39,343 women, cytologically screened over a 6 year interval suggests that true false negative cytology is an infrequent occurrence if adequate cellular samples are interpreted by competent cytologists. Cervical carcinoma, however, may be frequently suspected initially by the atypical smear and may primarily reflect coexistent dysplasia. After the initial screening examination, a significantly greater number of carcinomas will be detected through atypical smears. Invasive cervical cancer probably does not invariably follow a predictable period of dysplasia and in situ carcinoma; if such changes do precede the invasive lesion, the transition phase may be remarkably accelerated.

Treatment variables in the management of endometrial cancer

A review was made of 240 women with endometrial carcinoma who were treated at the University Hospital in Seattle, Washington, between 1961 and 1979. The most common predisposing factor was a history of exogenous hormones, elicited in 46.7%. As predicted, such patients exhibited a more favorable outcome. Twelve percent of patients developed recurrent disease, and the vagina was the most common site of recurrence. However, 85% of patients with vaginal recurrence had received preoperative radiation therapy. Nodal sampling was a phase of the primary surgical treatment of the disease in 41 of the 240 patients. An effort to focus on this issue was made by including in a separate review 26 additional patients similarly managed in 1980 and 1981, thereby raising to 67 the total number of patients with nodal sampling. Fifty-nine of these patients had Stage I endometrial cancer. In these patients, histologic grade of tumor and depth of invasion determined at the time of operation appear to serve as reasonable predictors of nodal involvement.