Hisham K. Tamimi

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.

The effect of body mass index on clinical/pathologic features, surgical morbidity, and outcome in patients with endometrial cancer.

OBJECTIVE To evaluate the effect of body mass index (BMI) on clinical/pathologic features, surgical morbidity, and outcome in patients with endometrial cancer. METHODS All women with surgically treated endometrial cancer at the University of Washington in Seattle, Washington, between 1 January 1990 and 1 January 2000 were eligible; 439 patients were identified and 43 were excluded due to incomplete medical records; 396 patients underwent retrospective chart review. Statistical analysis was performed by SPSS. Median follow-up time was 27 months (range, 1 to 120 mo). RESULTS Mean BMI was 34 (range, 15 to 69). BMI was <30 in 40.7% of patients, 30 to 40 in 32.3%, and >40 in 27.0%. Clinically, patients with a BMI of >40 were more likely to have hypertension, diabetes, and pulmonary disease. Those patients with a BMI of >40 had statistically longer operating times (209 vs. 159 min) and more blood loss (604 vs. 324 ml) than patients with a BMI of <30. However, there was no difference between the three groups in number of lymph nodes removed, units of blood transfused, length of hospital stay, number of intensive care unit (ICU) days, or intraoperative complications. Postoperatively, patients with a BMI of >40 were more likely to have a wound separation than thinner patients. Pathologically, patients with a BMI of >40 were more likely to have endometrioid histology, lower stage disease, and lower grade tumors than women with a BMI of <30. However, 11.3% of patients with lymph node sampling and a BMI of >40 had positive lymph nodes and 23% were stage II or higher. Forty-two patients (10.6%) recurred. There were no postoperative deaths, and there was no difference in survival between the three groups. CONCLUSIONS Patients with a BMI of >40 frequently have favorable stage I endometrial cancers. However, approximately a quarter of these patients have evidence of cervical or extrauterine disease. This study confirms that surgical staging can be performed adequately and safely in morbidly obese patients with no difference in length of hospital stay, number of ICU days, intraoperative or postoperative complications.

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.

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.

Enchondromatosis (Ollier's disease) and ovarian juvenile granulosa cell tumor. A case report and review of the literature

An ovarian juvenile granulosa cell tumor in a 15‐year‐old white girl is reported. The patient had enchondromatosis (Olliers disease), and a reivew of the literature revealed two previous reports linking enchondromatosis with ovarian sex‐cord stromal tumors. This heretofore unrecognized association between these two unusual lesions indirectly supports a generalized mesodermal dysplasia in patients with enchondromatosis. It also draws attention to the possible emergence of ovarian neoplasms in addition to the more frequently encountered chondrosarcomas.

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.

Prognostic impact of lymphadenectomy in clinically early stage malignant germ cell tumour of the ovary

Background:The aim of this study was to determine the impact of lymphadenectomy and nodal metastasis on survival in clinical stage I malignant ovarian germ cell tumour (OGCT).Methods:Data were obtained from the National Cancer Institute registry from 1988 to 2006. Analyses were performed using Students t-test, Kaplan–Meier and Cox proportional hazard methods.Results:In all, 1083 patients with OGCT who have undergone surgical treatment and deemed at time of the surgery to have disease clinically confined to the ovary were included 590 (54.48%) had no lymphadenectomy (LND−1) and 493 (45.52%) had lymphadenectomy. Of the 493 patients who had lymphadenectomy, 441 (89.5%) were FIGO surgical stage I (LND+1) and 52 (10.5%) were upstaged to FIGO stage IIIC due to nodal metastasis (LND+3C). The 5-year survival was 96.9% for LND−1, 97.7% for LND+1 and 93.4% for LND+3C (P=0.5). On multivariate analysis, lymphadenectomy was not an independent predictor of survival when controlling for age, histology and race (HR: 1.26, 95% CI: 0.62–2.58, P=0.5). Moreover, the presence of lymph node metastasis had no significant effect on survival (HR: 2.7, 95% CI: 0.67–10.96, P=0.16).Conclusion:Neither lymphadenectomy nor lymph node metastasis was an independent predictor of survival in patients with OGCT confined to the ovary. This probably reflects the highly chemosensitive nature of these tumours.

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.