Emmanuel Diakomanolis

Phase II Trial of Paclitaxel and Cisplatin in Metastatic and Recurrent Carcinoma of the Uterine Cervix

PURPOSE Both paclitaxel and cisplatin have moderate activity in patients with metastatic or recurrent cancer of the cervix, and the combination of these two agents has shown activity and possible synergism in a variety of solid tumors. We administered this combination to patients with metastatic or recurrent cervical cancer to evaluate its activity. PATIENTS AND METHODS Thirty-four consecutive patients were treated on an outpatient basis with paclitaxel 175 mg/m2 administered intravenously over a 3-hour period followed by cisplatin 75 mg/m2 administered intravenously with granulocyte colony-stimulating factor support. The chemotherapy was administered every 3 weeks for a maximum of six courses. RESULTS Sixteen patients (47%; 95% confidence interval, 30% to 65%) achieved an objective response, including five complete responses and 11 partial responses. Responses occurred in 28% of patients with disease within the radiation field only and in 57% of patients with disease involving other sites. The median duration of response was 5.5 months, and the median times to progression and survival for all patients were 5 and 9 months, respectively. Grade 3 or 4 toxicities included anemia in 18% of patients and granulocytopenia in 15% of patients. Fifty-three percent of patients developed some degree of neurotoxicity; 21% of cases were grade 2 or worse. CONCLUSION The combination of paclitaxel with cisplatin seems relatively well tolerated and moderately active in patients with metastatic or recurrent cervical cancer. The significant incidence of neurotoxicity is of concern, and alternative methods of administration of the two agents could be evaluated. Then, further study of this combination, alone or with the addition of other active agents, is warranted.

Management of ureteric injuries during gynecological operations: 10 years experience

OBJECTIVE(S) To present our 10 years experience in the management of ureteric injuries occurring during gynecological surgery. STUDY DESIGN Seventy-six patients had a variety of injuries. In 29 cases, the ureteric damage was diagnosed intraoperatively. Management of early-diagnosed injuries included suturing, ligature removal, end-to-end anastomosis, and reimplantation of the ureter. In 47 cases, the injury was diagnosed postoperatively. Ureteric catheterization was attempted in all cases presenting with obstruction. Catheterization failures were managed with ureterolysis, and reimplantation. Small ureteric fistula were managed with catheterization, and large communications with reimplantation. Two cases with urinomas were treated with surgical evacuation and anastomoses. RESULTS Management of early-diagnosed injuries was relatively easy in most cases. Postoperatively-diagnosed injuries were more difficult to treat. Catheterization failed in 28/44 (65.9%) ureters and surgical re-exploration was necessary. Long-term morbidity was minimal and no relapses occurred. CONCLUSION(S) Early recognition of a ureteric injury is the key to a complications-free repair. Unrecognized injuries cause prolonged morbidity, and their management can be difficult. Treatment of these injuries by experienced teams may minimize long-term consequences.

Dynamic Spectral Imaging: Improving Colposcopy

Purpose: Colposcopy occupies a key role in the prevention of cervical cancer by identifying preinvasive or invasive lesions. However, colposcopy is subjective and is responsible for 52% of screening failures. Dynamic spectral imaging (DSI) is based on the objective, quantitative assessment of the acetowhitening effect. This study compared DSI with colposcopy. Experimental Design: Women referred for colposcopy were examined simultaneously with colposcopy and DSI using a precommercial DySIS model (FPC-03) in an international, multicenter trial. The colposcopy impression and DySIS values were compared with consensus histology reports of biopsies. Subjects were recruited to a training group and subsequently to a test group. Measures were taken to avoid verification bias. Results: The training and test groups comprised 82 and 308 eligible women, respectively. A cutoff value to identify high-grade disease was selected from the results of the training group and data from previous work. Receiver operator curve analysis of the test data showed an area under the curve of 0.844. DySIS detected 62.9% more high-grade cases than colposcopy (57 versus 35, P = 0.0001). DySIS exceeded end points approved by the Food and Drug Administration for similar studies, with increments in the true positive rate of 22/308 (7.1%; lower 95% CL, 4.5% versus 2%) and in the false positive rate of 32/308 (10.4%; upper 95% CL, 14.7% versus 15%). Conclusions: DySIS is more sensitive than colposcopy in detecting high-grade lesions and can provide improved guidance for biopsy. The results are obtained in a user-independent fashion, making it suitable for use by nursing personnel.

Miliary Tuberculous Peritonitis Mimicking Advanced Ovarian Cancer

Primary peritoneal tuberculosis is a rare presentation of this disease. It is usually associated with ascites and raised CA-125 levels. Occasionally a pelvic mass may be present making the preoperative differential diagnosis from advanced ovarian cancer extremely difficult. Acid-fast stains and special cultures of the ascitic fluid for Mycobacterium tuberculosis are frequently negative, and confirmation of the diagnosis commonly requires histologic examination of biopsy specimens, in which epithelioid granulomas with central caseous necrosis can be identified. We present a case of unexplained pyrexial ascites in a postmenopausal woman in whom the diagnosis of miliary peritoneal tuberculosis was confirmed laparoscopically. The role of noninvasive tools such as measurement of ascitic fluid adenosine deaminase levels is also discussed.

Vulvar angiokeratoma following radical hysterectomy and radiotherapy

Angiokeratomas of the vulva are rare, benign tumors that present mostly on the labia majora. This is the first case report presenting a patient with this type of neoplasia, after radical hysterectomy and radiotherapy. Possible mechanisms for its pathogenesis could be increased venous pressure resulting from a hysterectomy or the loss of elastic tissue around the vessels from radiation, resulting in the formation of telangiectasias. Angiokeratomas should be included in the differential diagnosis of vulvar tumors in all women who have been treated for a lower genital tract malignancy.

p16 INK4A Is a Strong Biomarker for Cervical Intraepithelial Neoplasia and Invasive Cervical Carcinoma: A Reappraisal

To assess the role of p16 INK4A, bcl-2, and p53 in cervical cancer screening, we conducted a retrospective trial of prospectively collected data. Sixty two women with abnormal Pap smears were subjected to colposcopy and biopsies from any abnormal lesion. Human papillomavirus (HPV)-DNA typing, histology, and immunochemistry for p16INK4A, bcl-2, and p53 were performed for these women. Histologic diagnosis was that of low grade squamous intraepithelial lesion (LSIL), high grade squamous intraepithelial lesion (HSIL), or cancer in all cases. Human papillomavirus strains were identified in 56 patients (90.3%). All HSIL and invasive cancer cases were HPV positive. p16INK4A immunostaining yielded 100% sensitivity, 76% specificity, 61% positive predictive value, and 100% negative predictive value in cancer patients. The corresponding performance indicators for HSIL patients were 75%, 62%, 32%, and 91%. bcl-2 and p53 expression did not correlate with worsening grades of cervical disease. We conclude that p16INK4A seems to be a sensitive biomarker of high grade cervical intraepithelial neoplasia and cancer.

Coexistence of verrucous and squamous carcinoma of the vulva

Aim:  To evaluate the coexistence of verrucous and squamous carcinoma of the vulva and to assess the clinical course, survival and rate of recurrent disease of these patients.

Fecundity of infertile women with minimal or mild endometriosis

Abstract Despite significant developments in medical and surgical approaches for treating endometriosis, the optimal therapy has yet to be established. The relationship between prevalence of fecundity and stage of endometriosis according to their management was studied. Of 151 consecutive women with laparoscopy-proved endometriosis stage-1 and 2, operative laparoscopy was performed in 49, medical treatment in 59 and expectant management in 43 cases. During a 24-month period the cumulative pregnancy rates were found to be 36.7%, 30.5% and 20.9% respectively. Survival analysis showed that the probability of carrying the pregnancy beyond 20 weeks were 30.6%, 25.4% and 16.2% respectively. Diagnosis and treatment of early endometriosis is beneficial for the infertile women. Laparoscopic surgery seems to be the milestone of treatment in these cases, increasing the fecundity and involving minimal risk.

Intramural leiomyoma of the bladder

Mesodermal tumors of the urinary bladder are rare and the majority of them are malignant. We report a case of an intramural leiomyoma of the bladder presenting with symptoms of a mild lower urinary tract infection. The patient was managed with partial cystectomy and the outcome was excellent.

Colposcopically directed biopsy findings in the young female.

STUDY OBJECTIVE To evaluate the colposcopic findings of cervical alterations in the young sexually active female. DESIGN, SETTING, PARTICIPANTS Colposcopic examination and follow-up of 51 young sexually active females aged 15-20 yr was conducted due to abnormal cytology or a suspicious abnormality of the cervix. The study was conducted at the Colposcopy Units of the 1(st) and 2(nd) Departments of Obstetrics and Gynecology, University of Athens, Greece. ONTERVENTIONS: Colposcopic examination, LEEP, conization. MEAN OUTCOME MEASURES Biopsy, human papillomavirus (HPV) typing. RESULTS Colposcopic examinations were within normal limits in 8 of 51 (15.7%) cases. Cervical alterations were related to HPV infection in 14 cases (27.4%), to cervical intraepithelial neoplasia (CIN) I in 15 (29.4%) cases, to CIN II in 13 (25.5%) cases, and to CIN III in 1 (2.0%) case. Of all CIN I cases, 8 of 15 (53.3%) were HPV positive, and HPV type 11, 16, 18, 31, 33, and 11& 16 were found. In CIN II cases, 5 of 13 (38.4%) were HPV positive, and HPV type 11, 16, 18, and 11 & 31 were found. In the CIN III case, only HPV type 16 was found. CONCLUSIONS Our findings strongly confirm the necessity of obtaining cervicovaginal smears on all sexually active gynecologic and obstetric teenage patients. Colposcopy plays a major role in the evaluation of the cervix and in the treatment that should be given for any individual CIN lesion.