Dean R. Goplerud

Uterine sarcoma: analysis of prognostic variables in 71 cases.

The histories of 94 patients with a diagnosis of uterine sarcoma, treated from 1962 to 1982, at the Medical College of Virginia Hospital were reviewed. Histologic features were studied by one of the authors (V.S.), and cases that did not meet strict pathologic criteria were rejected. The 71 patients with uterine sarcoma accepted for this study had a survival rate of 22.5% from 1 to 11 years. Survival rates were similar for leiomyosarcoma, mixed mesodermal tumor, and endometrial stromal sarcoma. Clinical staging had some predictive value, since 45 patients with Stage I disease had a 27% survival rate, and 26 patients with Stages II, III, and IV disease had only a 12% survival rate (p less than 0.05). The type of treatment had no demonstrable effect on final outcome but did influence the recurrence patterns. Chemotherapy (used in 25 patients) was neither of benefit when used as adjuvant therapy nor effective in prolonging survival in patients with recurrence (mean survival, 5.4 months).

Mechanical intestinal obstruction in atlents with gynecologic disease: A review of 368 patients

To review the management of intestinal obstruction associated with gynecologic disease, the authors studied the records of 368 patients with acute intestinal obstruction. Most patients (83%) had gynecologic malignancies. Obstruction of the small intestines was more common than obstruction of the large intestines (77% versus 23%). Major causes of mechanical small bowel obstruction included extrinsic neoplasms (62%, mostly ovarian carcinomas), radiation therapy-associated strictures and adhesions (17%), postoperative adhesions (14%), and inflammatory strictures and adhesions (3%). Obstruction of the colon was caused mainly by extrinsic neoplasms (45%), strictures and adhesions associated with radiation therapy (26%), fecal impaction (9%), and intrinsic neoplasms (8%). Gastrointestinal intubation successfully relieved 81% of small bowel obstructions caused by postoperative adhesions. Tube suction alone was rarely successful when the obstruction was caused by malignant neoplasms. The prognosis was dependent on the cause of the underlying disease. The cases studied in this report were compared with a large number of cases of bowel obstruction in general surgery. It is concluded that bowel obstruction associated with gynecologic disease has unique features deserving wider recognition.

Computed Tomography in the Evaluation of Carcinoma of the Ovary

Over a 26 month period, 34 patients with histologically proven ovarian malignancy were studied by computed tomography (CT). In nine patients, CT was obtained for evaluation of a pelvic or abdominal mass. Computed tomography was diagnostic of ovarian malignancy in seven and indeterminate regarding the origin of the tumor in two patients. Ten patients were evaluated by CT in order to rule out recurrent ovarian neoplasm. Disease free intervals prior to CT ranged from 6 to 36 months with an average of 18 months. In eight surgically proven cases, CT was true positive for recurrent tumor in six patients, true negative in one, and false positive in one. In 20 patients, serial CT examinations were valuable in the objective assessment of measurable tumor response following chemotherapy and radiation therapy. A major limitation of CT was its inability to detect peritoneal and liver surface implants smaller than 2 cm in size.

Epithelioid sarcoma of the vulva

Abstract The authors present the third known case of an epithelioid sarcoma involving the vulva. This case illustrates the confusion that can occur in making a proper pathologic diagnosis. The histologic and electron microscopic characteristics of the tumor are presented. The natural history of the disease is discussed describing the propensity for local recurrence and the sites of metastases. Recommendations for management are discussed.

A pilot study of concomitant boost accelerated superfractionated radiotherapy for stage III cancer of the uterine cervix

PURPOSE Retrospective studies suggest that prolonged treatment time adversely affects control rates of squamous carcinomas managed by radiotherapy. From 1989 to 1994 a prospective clinical trial was conducted to assess the feasibility and efficacy of concomitant boost accelerated superfractionated (CBASF) radiotherapy for advanced uterine cervical carcinoma. METHODS AND MATERIALS Twenty newly diagnosed patients with FIGO stage III squamous cell carcinoma of the cervix were irradiated using a CBASF regimen. Patients received 45 Gy administered to the whole pelvis in 25 fractions in 5 weeks. On Monday, Wednesday, and Friday of the last 3 weeks, an additional 1.6 Gy boost was given 6 hours after the whole pelvis treatment. The 9 boost treatments, totaling 14.4 Gy, were given via lateral fields encompassing the parametria and primary tumor for a cumulative tumor dose of 59.4 Gy. A single low-dose rate brachytherapy procedure was performed within 1 week after the external beam radiotherapy to raise the point A dose to 85-90 Gy in 42 days. Primary endpoints of analysis were local control, complications, and patterns of failure. Results are compared with the outcomes of 21 patients treated with conventionally fractionated (CF) radiotherapy during the same years. RESULTS Median total treatment time was 46 days in the CBASF group (range 37-62). Median follow-up interval among surviving CBASF patients is 3.8 years. The four-year actuarial local control rates are 78% and 70% in the CBASF and CF groups, respectively (p = ns). Only 2 CBASF patients required a treatment break because of acute toxicity, but severe late complications occurred in 8/20 CBASF patients for a crude rate of 40%. Distant failure was more common than local failure in the CBASF group, and para-aortic node failure occurred in six of the eight CBASF patients with distant failure. CONCLUSIONS In the management of stage III cervix cancer, the CBASF regimen produced a trend toward improved local control when compared with the CF regimen, shifting the patterns of failure toward a higher rate of isolated distant failures. The high frequency of para-aortic node failure warrants consideration of elective treatment to this region in stage III patients treated with curative intent. Although the high local control rate of the CBASF regimen supports further investigation of accelerated treatment regimens for locally advanced cervix cancer, the unacceptable risk of late complications necessitates refinement in technique and scheduling to improve the therapeutic ratio.

Prolapsed fallopian tube masquerading as adenocarcinoma of the vagina in a postmenopausal woman

A postmenopausal patient with vaginal prolapse of the fallopian tube presented with an erroneous diagnosis of adenocarcinoma of the vaginal apex. Failure to consider fallopian tube prolapse in the differential diagnosis of vaginal adenocarcinoma led to an upper vaginectomy and subsequent complication of a ureterovaginal fistula. The differential diagnosis of adenocarcinoma of the vagina in the postmenopausal patient and the management of vaginal prolapse of the fallopian tube are discussed.

Expression of herpes simplex virus type 2 antigens in premalignant and malignant human vulvar cells

Vulvar biopsies and explants from patients with vulvitis, hyperkeratosis, condyloma acuminatum, severe dysplasia, and squamous cell carcinoma were screened for herpes simplex virus type 2 (HSV-2) antigens. Immunoperoxidase staining for VP143, an early nonstructural polypeptide of HSV-2, was identified within three biopsies exhibiting severe dysplasia, three of seven with carcinoma in situ, and one of three with invasive squamous cell carcinoma. Similar staining for VP143 was observed in derived explants. Staining for VP119, the major envelope glycoproteins of HSV-2, was identified within tissues which were positive for VP143. Both proteins were expressed in the absence of staining for virus capsid proteins, detection of virus structures by electron microscopy, and isolation of infectious virus by co-cultivation, indicating that only a fragment of the virus genome was expressed. Neither VP143 nor VP119 was identified in biopsies exhibiting vulvitis, hyperkeratosis, or condyloma acuminatum. These data indicate a close relationship between HSV-2 and vulvar neoplasia.

Combination antiemetic therapy in cisplatin-induced nausea and vomiting.

Twenty‐seven consecutive patients with advanced gynecologic malignancies undergoing chemotherapy with cisplatin in combination with other agents were studied in a prospective, randomized fashion to compare the antiemetic efficacy of a combination regimen with high‐dose metoclopramide. The combination regimen consisted of prochlorperazine, dexamethasone, and pentobarbital. Patients treated with the combination regimen had significantly less vomitus (P < 0.01, Students t test) and fewer vomiting episodes (P < 0.001, test for homogeneity) than patients treated with metoclopramide. In addition, the sedative and sleep‐inducing effect of the barbiturate made the experience of vomiting more tolerable, even in those instances where the combination regimen was not superior to metoclopramide in the control of vomiting.

Whole abdominal radiotherapy following cytoreductive surgery and chemotherapy in ovarian carcinoma

Persistent or recurrent disease following surgery and chemotherapy in ovarian carcinoma remains a major therapeutic dilemma. Between January 1980 and December 1985, there were 26 patients who had previously undergone cytoreductive surgery and chemotherapy and were treated with external beam radiotherapy. Twenty-one of these patients had been treated with platinum-adriamycin-cytoxan (PAC) regimen and 5 were treated with other combinations. Surgical reevaluation was performed in 21 of the 26 patients and only 4/21 (19%) patients were free of disease. All 26 patients were irradiated with a planned dose of 2500 cGy/100 cGy/day or 2280 cGy/120 cGy/day to the whole abdomen and a final calculated dose to the pelvis of 4500 cGy. Initial evaluation showed a 3-year actuarial survival rate of 51% and a disease-free survival rate of 42%. Follow-up analysis yields survivals of 45 and 35%, respectively. Severe gastrointestinal complications were observed in 3/26 patients and all hematologic complications resolved. Variables of prognostic significance were chemotherapy tolerance, grade, and volume of residual disease. We conclude that a proportion of patients with disease following cytoreductive surgery and chemotherapy may be salvaged with abdominopelvic irradiation.

A herpesvirus antigen in human premalignant and malignant cervical biopsies and explants

Cervical biopsies and explant cultures from patients with squamous metaplasia, various grades of dysplasia, carcinoma in situ (CIS), and invasive squamous cell carcinoma were screened for VP143, an early nonstructural polypeptide of herpes simplex virus type 2 (HSV-2), VP143 was identified in 31% of biopsies exhibiting severe dysplasia, 29% with CIS, and 41% with invasive squamous cell carcinoma. Similar results were obtained when explants derived from these biopsies were examined for VP143. The expression of the protein persisted in passaged subcultures in four of five invasive carcinomas which originally contained VP143. Staining for VP157, the major capsid protein of HSV-2, was absent. Furthermore, virus structures were not seen by electron microscopy and infectious virus was not isolated from cell cultures inoculated with biopsy extracts. These results suggest that VP143 was expressed in the premalignant and malignant cervical cells in the absence of productive viral infection. Thus, a fragment of the HSV-2 genome was retained within the cells, the expression of which resulted in the production of VP143.