Howard G. Muntz

Stage IE primary malignant lymphomas of the uterine cervix.

The experience of the authors with primary non‐Hodgkins lymphoma of the uterine cervix from 1980 to 1986 included five Ann Arbor Stage IE cases successfully managed by meticulous staging and radiation therapy. The clincopathologic features of the patients are described and compared with 38 previously reported Stage IE cases. When all 43 patients were evaluated, the median age was 40 years of age (range, 20 to 80 years of age) and 77% were premenopausal. Most patients (74%) reported abnormal vaginal bleeding, although approximately 20% were asymptomatic. The primary cervical tumors were typically of large size, with half exceeding 4 cm in diameter. Using the International Federation of Gynecology and Obstetrics (FIGO) system for staging cervical cancer, stage distribution was 44% Stage I, 42% Stage II, 12% Stage III, and 2% Stage IV. Histologically, approximately 70% were of the diffuse, large cell type (Working Formulation). External beam radiation therapy supplemented by brachytherapy or hysterectomy was used for 76% of the patients reviewed. There was only one treatment failure among the 28 patients whose treatment included radiation and whose cases were followed for at least 2 years. This experience and a review of the literature indicate that most cases of primary lymphoma of the uterine cervix are Ann Arbor Stage IE, and can be cured with traditional combinations of surgery and radiation therapy after careful evaluation.

Port-site recurrence after laparoscopic surgery for endometrial carcinoma.

BACKGROUND Women with endometrial carcinoma are being treated with laparoscopic surgery, but the risk of port-site recurrences remains undefined. CASE A 58-year-old woman underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic lymphadenectomy for endometrial cancer. Final surgical stage was IA, with grade 2 histology. Twenty-one months later, she developed a 5-cm recurrent tumor mass at a lateral laparoscopic port site. The mass was resected, and a restaging laparotomy performed, without evidence of other metastases. Radiation therapy was administered to the involved anterior abdominal wall. Two and one half years later, there is no evidence of recurrence. CONCLUSION An isolated laparoscopic port-site recurrence might be attributable to the initial laparoscopic management of an otherwise good-prognosis endometrial carcinoma.

Combined Weekly Topotecan and Biweekly Bevacizumab in Women With Platinum- Resistant Ovarian, Peritoneal, or Fallopian Tube Cancer

A phase 2 trial was conducted to determine the toxicity and efficacy of combined weekly topotecan and biweekly bevacizumab in patients with primary or secondary platinum‐resistant ovarian, peritoneal, or fallopian tube cancer (OC).

Carcinosarcomas and mixed müllerian tumors of the fallopian tube

Four cases of carcinosarcoma and mixed müllerian tumors of the fallopian tube are presented. Each patient presented with abnormal bleeding and a pelvic mass. All underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, staging, and cytoreduction. Disease was limited to the pelvis in two patients, analogous to FIGO stage IIB ovarian carcinoma; the other two patients had upper abdominal disease, analogous to FIGO stage III. The primary tumors were intraluminal and papillary. There were equal amounts of carcinoma and sarcoma in three tumors; in one, sarcoma constituted only a small intraluminal focus. The sarcoma was predominantly homologous, with foci of heterologous elements present in three tumors. Adjuvant therapy consisted of pelvic radiation in two patients. One patient died of inanition within one year of diagnosis. The other patient, who had the small focus of sarcoma within a stage IIB carcinoma, had an 11-year disease-free interval before retroperitoneal recurrence of carcinoma. Two patients received chemotherapy. A stage IIB patient, after pelvic radiation, received Cytoxan and Adriamycin; she is clinically free of disease after 6 years. A stage III patient lived over 3 years after treatment with multiple agents; she responded to Cytoxan and cis-platinum before suffering a systemic relapse and death.

Oncogene expression: long-term compared with short-term survival in patients with advanced epithelial ovarian cancer.

Objective To determine if oncogene overexpression in patients with advanced epithelial ovarian cancer correlates with survival. Methods Twenty-two women with stage III ovarian cancer, observed for a median of 66 (range 48–204) months were compared with 30 with a median survival of 18 (range 2–28) months. Using immunocytochemistry, tumors were immunostained for overexpression of p53, c-erb-B-2, and epidermal growth factor receptor and were evaluated quantita-tively for expression of estrogen receptor, progesterone receptor, and Ki-67 antigen, a marker of cellular proliferation. Results The median age of long-term survivors was 52 (range 30–76) years compared with 55 (range 36–80) years for short-term survivors. Optimal cytoreduction was achieved in 11 of the 22 long-term survivors compared with seven of the 30 short-term survivors, a significant difference (P = .05). The average level of Ki-67 expression was 43% in long-term survivors and 64% in short-term survivors (P = .007). Overexpression of p53 was seen in 54% of long-term survivors and 80% of short-term survivors (P = .05). A combination of Ki-67 level of 50% or greater plus p53 overexpression was seen in 22% of long-term survivors compared with 68% of short-term survivors (P = .005). Epidermal growth factor receptor, c-erb-B-2, estrogen receptor, and progesterone receptor statuses did not differ significantly between the two groups. Conclusion Markers that did not correlate with survival included the hormone receptors, estrogen receptor and progesterone receptor, and the oncogenes, c-erb-B-2 and epidermal growth factor receptor. Long-term survivors with ad-vanced ovarian cancer were more likely to have had an optimal cytoreduction and lower levels of Ki-67 antigen expression and were less likely to overexpress p53 than were short-term survivors.

Serum lactic dehydrogenase as a tumor marker in dysgerminoma

Dysgerminoma is the most common malignant germ cell tumor in young women. The management of advanced-stage dysgerminoma challenges the gynecologic oncologist to achieve maximal survival, while maintaining childbearing potential. Radiation therapy has been extremely successful in curing dysgerminoma, but ovarian conservation is usually not possible. In contrast, various chemotherapeutic regimens have achieved high cure rates with continued ovarian function. Diagnosing recurrent dysgerminoma promptly so that salvage therapy can be initiated is important when conservative management has been employed. While alpha-fetoprotein and human chorionic gonadotropin have proven useful as tumor markers in some types of germ cell tumors, they have not been useful in patients with dysgerminoma. Serum lactic dehydrogenase (LDH) levels are known to be elevated in some patients with dysgerminoma. We treated a patient with Stage IIIC dysgerminoma whose initial serum LDH level was markedly elevated. After unilateral salpingo-oophorectomy with pelvic and paraaortic lymphadenectomy, followed by four cycles of VAC chemotherapy, her LDH level returned to normal. Her LDH level rose with disease recurrence and returned to normal again with salvage BEP chemotherapy. This is the first report to document the utility of serial LDH measurements in detecting disease recurrence in patients with ovarian dysgerminoma.

Combination chemotherapy in advanced adenocarcinoma of the fallopian tube

Abstract Advanced adenocarcinoma of the fallopian tube has a poor prognosis, with 5-year survival rates commonly less than 20%. Since 1980, we have managed 12 patients with disseminated tumor with combination chemotherapy following surgical cytoreduction. Analogous to the International Federation of Gynecology and Obstetrics staging of ovarian carcinoma, 3 patients were classified in Stage II, 8 in Stage III, and 1 in Stage IV. Ten patients received cisplatin-containing regimens. The 3 Stage II patients, without measurable disease after primary surgery, had an indeterminate response to chemotherapy. In Stages III–IV there were 4 complete responses (3 confirmed by second-look laparotomy) and 2 partial responses, for an overall response rate of 67%. Disease progressed in 2 patients and was stable in 1 patient. After median follow-up of 3.5 years, 4 of the Stage III–IV patients have no evidence of disease, 1 is alive with disease, and 4 are dead.

Adenocarcinoma of the uterine cervix metastatic to lymph nodes

OBJECTIVE We set out to evaluate the prognostic factors in cervical adenocarcinoma metastatic to lymph nodes. STUDY DESIGN We performed a retrospective review of 40 patients with cervical adenocarcinoma and lymph node metastasis from 1976 to 1996. RESULTS Thirty-four patients had adenocarcinoma, and six had adenosquamous carcinoma. Median survival was 50 months. The median survival for patients with stage I disease was 69 months. Stage at diagnosis, treatment with radical hysterectomy, and receiving adjuvant therapy were associated with prolonged survival. A trend toward improved survival was noted with the use of concurrent radiation and chemotherapy as an adjuvant therapy. CONCLUSIONS Adenocarcinoma metastatic to the lymph nodes does not have a uniformly poor prognosis, especially with early-stage disease. Improved survival was observed with the use of adjuvant therapy, specifically the use of combined chemotherapy and radiation after radical hysterectomy. The optimal therapy in this setting is yet to be determined.

Phase 2 study of intraperitoneal topotecan as consolidation chemotherapy in ovarian and primary peritoneal carcinoma

Intravenous topotecan is approved for the treatment of ovarian cancer (OC). In intraperitoneal (i.p.) topotecan studies, 20 mg/m2 dosing was tolerable. This study evaluated the feasibility, safety, and preliminary efficacy of i.p. topotecan as consolidation chemotherapy in patients with OC or primary peritoneal cancers (PPCs).

Lower limb compartment syndrome as a complication of radical hysterectomy

Highlights • Compartment syndrome is a rare complication of prolonged lithotomy position.• We report a case of compartment syndrome complicating radical hysterectomy.• Prompt diagnosis is crucial to reduce morbidity from compartment syndrome.• Awareness of this complication allows surgeons to address modifiable risk factors.