Herbert J. Buchsbaum

Long-term follow-up and prognostic factor analysis in advanced ovarian carcinoma: the Gynecologic Oncology Group experience.

Long-term follow-up was obtained on 726 women with advanced ovarian carcinoma (suboptimal stage III and stage IV) who had received primary chemotherapy on two Gynecologic Oncology Group (GOG) protocols between 1976 and 1982. The first study compared melphalan alone versus melphalan plus hexamethylmelamine versus cyclophosphamide plus doxorubicin (CA). The second study evaluated the same CA regimen with or without cisplatin. Eligibility for the two studies was the same. At last contact, 76 patients were alive. In a multivariate analysis, cell type other than clear cell or mucinous, cisplatin-based treatment, good performance status, younger age, lower stage, clinically nonmeasurable disease, smaller residual tumor volume, and absence of ascites were favorable characteristics for overall survival (P less than .05). Second-look laparotomy was negative significantly more often among those with endometrioid tumors; there were no negative second-look laparotomies among those with mucinous or clear cell tumors. There were 30 patients with suboptimal stage III disease who had a negative second-look laparotomy; 18 (60%) have experienced recurrence, and 13 (43%) have died. Although cisplatin treatment was beneficial, new treatments are clearly needed.

Extrapelvic lymph node metastases in cervical carcinoma

One hundred and fifty patients with invasive cervical carcinoma underwent preradiation therapy celiotomy and para-aortic node excision. The incidence of histologically documented metastases in these nodes was 33% (34/102) in Stage IIIB. The last 23 patients with positive para-aortic nodes had left sclanene node excision; nodes were positive in eight patients (34.8%). Sixteen patients had visceral metastases including 11 with small and large bowel metastases, two with liver metastases, and one with metastases to the liver and intestine. Pretreatment celiotomy with para-aortic lymph node excision and, where positive, followed by scalene lymph node excision is valuable in treatment planning in advanced cervical carcinoma limited to the pelvis.

Experience with peritoneal cytology in the management of gynecologic malignancies

Abstract A summary of a 21 year experience with peritoneal cytology obtained by cul-de-sac and peritoneal lavage is presented. The interpretation of this type of cytology requires well-trained, experienced cytologists. Vaginal cul-de-sac lavage in asymptomatic patients has not proved effective in the early detection of ovarian cancer. Peritoneal cytology obtained at operation, on the other hand, has promise of considerable value. It was positive in 78 per cent of patients with ovarian cancer. Significantly, malignant tumors with an intact capsule shed malignant cells into the peritoneal cavity in 36 per cent of Stage I a patients. The over-all percentage of positive cytology for Stage I a, b, and c tumors was 45 per cent. There were 39 cases of Stage I endometrial carcinoma, of which 12.8 per cent had positive cytology. In patients with Stage III cervical carcinoma, who were explored as a part of their primary treatment, 14.7 per cent of those with negative nodes and 55.5 per cent of those with positive nodes had postive peritoneal cytology. Evidence is presented to prove that shed cancer cells are viable and capable of continued growth and that some form of adjunctive therapy should be considered.

Para-aortic lymph node involvement in cervical carcinoma

Abstract The incidence of para-aortic lymph node involvement was studied in 34 patients with Stage II to IV cervical carcinoma. Histologic confirmation of nodal involvement, prior to the institution of therapy, was found in 8.3 per cent of patients with Stage II, 35 per cent of patients with Stage III, and in 1 of 2 patients explored with Stage IV cervical carcinoma. Additional findings included 2 cases of unsuspected bowel involvement, 2 with liver metastases, and 2 with ovarian carcinoma. Laparotomy prior to radiation therapy appears to be a safe and useful procedure.

Reexploration after treatment for ovarian carcinoma

Abstract Sixty-five patients with documented ovarian carcinoma who underwent a second exploratory celiotomy between 1969 and 1978 are presented. In 50 patients the second surgery followed appropriate staging, reduction surgery, and appropriate therapy. These patients could be divided into two groups: The first group consists of 24 patients who had no clinical or radiographic evidence of residual disease after appropriate therapy; the second group consists of patients explored after regression of disease, but with suspected or known residual (26 patients). No evidence of tumor was found in 21 of the 24 (27.5%) patients in the first group. Only one patient with a negative second-look operation developed a recurrence, and represents the only death from disease in the group. In the second group only 27% of the patients explored and found to have residual disease are alive. There were no surgical deaths or major surgical complications in either group. Indications and the operative technique for a second-look procedure are discussed.

Bony metastases from carcinoma of cervix Occurrence, diagnosis, and treatment

Fifty‐five patients treated for cervical carcinoma developed bony metastases between January 1, 1961 and December 31, 1973. Roentgenograms were diagnostic in all but 2 of the patients. In 15 patients, a combination of radioactive scans and roentgenograms was used to establish the diagnosis. The most common mechanism of bony involvement from carcinoma of the cervix was extension of the neoplasm from para‐aortic nodes, with involvement of the adjacent vertebral bodies. The earliest metastases were discovered at the time of the primary diagnosis. Thirteen years was the longest interval from the primary diagnosis until the discovery of bony metastases. Sixty‐nine percent of the patients were diagnosed within 30 months. Ninety‐six percent of the patients died within 18 months. Seventy‐six percent of the patients received some form of therapy for their metastases. Thirty‐six of these patients were treated with radiation therapy. Four of these patients received complete relief of symptoms, 24 some relief, and 8 patients received no relief.

Ovarian remnant syndrome: difficulties in diagnosis and management.

Ovarian remnant syndrome should be considered in the differential diagnosis of pelvic pain with a mass in a patient who has had extirpative surgery. Although rarely reported in the literature, it is probably much more prevalent than is suspected. Most commonly, the initial surgery was performed for endometriosis or pelvic inflammatory disease, with incomplete excision of the ovaries. Surgical excision of the ovarian remnant, the definitive treatment, is itself difficult, and is often attended by serious complications. Medical therapy is empiric, and hormonal manipulation may help prevent recrudescence. Three cases are reported, their pathology and the literature is reviewed.

Prophylactic chemotherapy in stages I and II uterine sarcoma.

Abstract Prophylactic chemotherapy was used following hysterectomy in patients with stages I and II uterine sarcoma. The outcome in this small group of patients appeared better than in a historical control. The findings suggest that there is a place for prophylactic or adjuvant chemotherapy following total hysterectomy in early-stage uterine sarcoma.

Omental sling for management of the pelvic floor following exenteration

Abstract Intestinal fistulas and obstruction are major problems following pelvic exenteration. These problems are directly related to the raw and denuded pelvic floor through which the intestines can prolapse and/or become adherent in a potentially infected field. A variety of techniques with the use of biological and nonbiological substitutes have been described. All have been found to have serious shortcomings. The omental sling described by Valle and Ferraris 6 has been used successfully in 12 patients. A method of lengthening the omentum is described which makes this technique more widely applicable. Five of the 12 patients required lengthening of the omentum before a sling could be created. There have been no problems related to intestinal prolapse, fistula, or obstruction in these 12 patients, with the longest follow-up being 33 months.

Pelvic exenteration for vulvovaginal carcinoma

Between 1964 and 1978, 16 pelvic exenterations were performed for advanced and recurrent vulvovaginal carcinoma. Eight patients had Stage III carcinoma and four had recurrent vulvar carcinoma. Ten patients had involvement of the anus/sphincter, and two had involvement of the proximal half of the urethra. There were four patients with vaginal carcinoma. Two patients with recurrent vaginal carcinoma had bladder/urethral involvement; one patient each with primary vaginal carcinoma had rectovaginal and vesicovaginal septal disease. Seven patients are alive and free of disease--six for more than 5 years and one for 4 years and 4 months. Three patients died, free of disease, one each of cerebrovascular accident, traumatic subdural hematoma, and pulmonary embolus. One patient died on the ninth postoperative day of aspiration pneumonitis. The absolute 5-year survival rate is 54%.