Jeffrey L. Stern

Cervical carcinoma: Computed tomography and magnetic resonance imaging for preoperative staging

Objective To assess the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) in the evaluation of invasive cervical cancer. Methods Seventy-nine women with untreated cervical cancer underwent pre-treatment MRI (n = 71) and/or CT (n = 37) within 4 weeks of surgical evaluation. Twenty-nine women had both MRI and CT. Images were evaluated for tumor detection, size, stromal invasion, local extension, and nodal metastases. Results Tumor size was evaluated accurately by MRI, with a correlation coefficient of 0.93. Magnetic resonance estimates of tumor size were within 0.5 cm of the surgical sample in 64 of 69 women (93%). Magnetic resonance was 88% accurate evaluating the presence of stromal invasion and 78% accurate for depth of stromal invasion. Computed tomography could not evaluate tumor size or stromal invasion because it could not distinguish cancer from the surrounding normal cervical tissue, In evaluating stage of disease, MRI had an accuracy of 90%, compared with 65% for CT (P < .005). Magnetic resonance imaging was more accurate than CT (94 versus 76%, P < .005) in assessing parametrial invasion. Both modalities were comparable in evaluating lymph node metastases (86% each). In determining operative candidates (stage I and minimal IIA), MRI was 94% accurate, compared with 76% for CT (P < .005). Conclusion Compared with CT, MRI offered significantly improved evaluation of tumor size, stromal invasion, and local and regional extent of disease in pre-treatment imaging for cervical cancer.

CARCINOMA OF THE CERVIX: PREDICTIVE VALUE OF CLINICAL AND MAGNETIC RESONANCE (MR) IMAGING ASSESSMENT OF PROGNOSTIC FACTORS

PURPOSE This retrospective study assesses the predictive value of magnetic resonance imaging (MRI) to identify high risk cervical cancer patients. METHODS AND MATERIALS The MRI evaluation of morphologic risk factors in patients with invasive cervical carcinoma treated with definitive radiation therapy were correlated with clinical factors and with complete tumor regression (CTR) at 6 months, tumor local control (TLC), and patient outcome at 12 months after irradiation. Sixty-six patients, median age 44.5 years, with bulky Stage I or greater disease were included in the study. RESULTS In univariate analysis, clinical International Federation of Gynecology and Obstetrics (FIGO) stage had significant correlation with patient outcome, but it correlated poorly with complete tumor regression and tumor local control. In contrast, MRI stage showed significant correlation with complete tumor regression, tumor local control, and disease-free survival at 12 months. When each stage was analyzed separately, the greatest difference was demonstrated between clinical and MRI assignment of stage Ib disease. MRI Stage Ib disease significantly correlated with all three categories analyzed, while clinical Stage Ib did not. Superiority of MRI assessment of low stage disease was also evident in the detection of lymph node metastasis. Significant risk for nodal metastasis was related to tumor size greater than 4 cm, invasion of the parametria and urinary bladder, and stage of the disease. CONCLUSION The multivariate analysis demonstrated that the most related variables in order of significance were the presence of juxta-regional and paraaortic lymph nodes, patient age, tumor size, and MRI tumor stage. This study demonstrates the value of MR imaging as an adjunct to clinical assessment of bulky invasive cervical cancer, rendering more complete assessment of morphologic risk factors important in patient prognosis.

Desmoplastic small cell tumor of the ovary: a unique polyphenotypic tumor with an unfavorable prognosis

Desmoplastic small cell tumor (DSCT) is a recently described intraabdominal neoplasm of uncertain histogenesis that occurs predominantly in boys and young men. We report a case in a young woman that presented clinically as bilateral ovarian tumors with extensive pelvic and abdominal dissemination. The patient had cytoreductive surgery followed by combination chemotherapy. She had a complete clinical remission, but tumor recurrence was detected 1 year after diagnosis and the patient died of her disease 18 months after presentation. DSCT has a distinctive histologic appearance and a unique immunophenotype. It can present as an ovarian neoplasm and must be considered in the differential diagnosis of small cell tumors of the ovary.

Vaginal reconstruction after exenteration with use of gracilis myocutaneous flaps: The University of California, San Francisco experience☆

At the University of California, San Francisco Medical Center we have performed 18 vaginal reconstructive procedures with gracilis flaps at the time of anterior, posterior, or total pelvic exenteration. We have compared these patients with 13 other patients undergoing exenteration during the same interval who chose not to have vaginal reconstruction. There was no significant difference between the two groups with respect to age, weight, operating time, blood loss, or duration of postoperative hospitalization, but there were significantly fewer serious complications in the patients receiving gracilis flaps. The results of a questionnaire indicated that the perineal cosmetic results are highly acceptable, although residual scarring on the legs is a common source of minor complaint. Sexual adjustment can be complete or nearly complete in surviving patients. Given the major contribution to wound healing, reduced postoperative morbidity, excellent cosmetic results, and the opportunity for complete sexual rehabilitation, we believe the gracilis myocutaneous flap neovagina remains the procedure of choice for most women undergoing major exenterative procedures.

Preventing cervical Ionization by achieving satisfactory colposcopy with hygroscopic cervical dilators

Eighteen women with abnormal cervical cytologic findings and unsatisfactory colposcopic examinations underwent cervical dilatation with Dilapan (Gynotech), a hygroscopic dilator. Dilatation exposed the entire squamocolumnar junction, converting an unsatisfactory colposcopic examination into a satisfactory one and avoiding cervical conization in 17 of the patients.

Comparison of diagnostic studies in the pretreatment evaluation of stage Ib carcinoma of the cervix.

The results of our study highlight the need for change in the pretreatment workup of clinical stage Ib cervical cancer. The routine use of excretory urography, barium enema, cystoscopy,and sigmoidoscopy is not justified. MR evaluation is recommended in patients with lesions larger than 2 cm (the group with the greatest increase in predictive value). Although CT scanning is not recommended for the evaluation of parametrial invasion, both CT scanning and MR imaging provide similar positive and negative posttest probabilities for the evaluation of nodal disease.

Salvage whole-abdominal irradiation following chemotherapy failure in epithelial ovarian carcinoma

During the period 1977 to 1985, 12 patients with FIGO stage II and III epithelial ovarian carcinoma failed to achieve a pathologic complete response with chemotherapy and underwent salvage whole-abdominal irradiation (WAXRT). Six of these patients had gross residual disease present at the time of irradiation, and three (50%) were unable to complete the planned radiotherapy. All eventually failed in the treatment field; their 5-year actuarial survival and local control rates were zero. The other six were irradiated without residual macroscopic disease. Five of the six (83%) were able to complete WAXRT as planned without prolonged delays. The 5-year actuarial survival and local control rates for this group were 21 and 25%, respectively. The actuarial laparotomy rate to relieve bowel obstruction following WAXRT was 40% at 2 years. The results from this and other series indicate that salvage WAXRT is not effective for patients irradiated with macroscopic tumor. However, WAXRT appears to be potentially curative for a small but significant percentage of patients irradiated without gross disease, although the risk of significant complications is high.

4 Vulvovaginal reconstruction following radical surgery

Summary An important aspect of the care of women with a gynaecological malignancy is not only improved survival, but complete rehabilitation. There are a number of reconstructive techniques available which can be used at the time of radical surgery, or at some later date, to correct the untoward effects of therapy. Whenever possible, the least morbid, yet most reliable reconstructive procedure should be performed at the initial surgery to decrease postoperative morbidity and wound infection and improve rehabilitation and body image. For many situations there is no single ideal procedure, therefore one should be familiar with several techniques in order to select or adapt the procedure best suited to the circumstances. The split thickness skin graft (STSG) is used primarily to cover skin defects where there has been little or no loss of subcutaneous tissue, such as after skinning vulvectomy for carcinoma in situ. It is also the procedure of choice for vaginal reconstruction after simple vaginectomy for extensive in situ carcinoma and for congenital absence of the vagina. It may also be useful in the management of vaginal distortion, secondary to previous surgery or radiation therapy. In gynaecology, full thickness skin flaps are used when there has been major loss of skin and subcutaneous tissue of the vulva, groin or vagina. Defined arterial and fasciocutaneous flaps are more reliable than random cutaneous flaps, but they are not mutually exclusive in their application. Thus, one or the other may be used for the same defect in differing patients, depending on the situation. Circumstances that dictate which flap is preferable include size, contour, depth of the deformity, proximity of the deformity to the potential donor site, presence of necrosis and infection, and the requirement for new blood supply, as in an irradiated wound. In appropriately selected patients the myocutaneous flap will provide the most reliable source of a new blood supply. If the requirement for a new blood supply is of paramount importance, and the myocutaneous flap is too thick, the skin and subcutaneous tissue may be sacrificed to reduce the size of the flap. A STSG can then be applied at a later time to achieve the desired result. There are many other situations when several reconstructive procedures used simultaneously, or serially, may be required to achieve a balance between anatomy and function. However, ultimate success will depend largely on patient selection, familiarity with the procedures, and exacting surgical technique.

Fine-needle aspiration biopsy in the management of cervical carcinoma following primary therapy

Thirty-five fine-needle aspiration biopsies (FNAB) in 30 patients who had previously received primary therapy for cervical carcinoma are reported. There were 22 positive FNABs, and in 11 cases the positive FNAB definitely changed the patients planned therapy. There were no complications due to FNAB in these 30 patients. FNAB has an important role in follow-up and management of patients with cervical carcinoma.