Leon L. Adcock

Trophoblastic pseudotumor—Evidence of malignant disease potential

Abstract Trophoblastic pseudotumor, the histopathologic entity described by Kurman and associates (R. J. Kurman, R. E. Scully, and H. J. Norris, Cancer 38 , 1214–1226 (1976)), has been considered in the scheme of gestational trophoblastic neoplasia as an exaggerated form of syncytial endometritis and, therefore, associated with a benign outcome. The manifestation of malignant sequalae and ultimate demise of a patient in a recognized case of trophoblastic pseudotumor is presented. Light and electron microscopic studies and autopsy findings are discussed. Therapies, both surgical and chemotherapeutic, and serum assay of the β subunit of human chorionic gonadotropin are correlated to the clinical course.

The role of surgical debulking in cancer of the uterine cervix

From 1978 to 1985, 159 women with advanced cervical cancer received definitive radiation therapy following extraperitoneal surgical staging including pelvic lymph node dissection and periaortic lymph node sampling. Relapse-free survival was a strong function of peritoneal and nodal metastases but was independent of clinical stage. The 5-year relapse-free rate fell from 86% in women without pelvic node metastases to 0% in those with unresectable pelvic node metastases. Women with microscopically positive pelvic node metastases had virtually the same (56%) relapse-free rate as those with grossly positive but completely resected metastases (57%). The overall pelvic failure rate was 16.4% and was significantly higher in women with unresectable pelvic node metastases. Periaortic and peritoneal metastases substantially increased the probability of recurrence. Although histologic grade was prognostically significant, histopathologic category was not. Severe enteric morbidity occurred in 3.6% of patients treated solely to the pelvis and in 7.9% of patients treated to the pelvis and periaortics. Therapeutic implications of debulking pelvic node metastases are discussed.

Prognostic significance of the presence of human papillomavirus DNA in patients with invasive carcinoma of the cervix

Cases of invasive carcinoma of the uterine cervix were analyzed to determine whether the presence or absence of human papillomavirus (HPV) DNA in the neoplasms was a contributing factor to their outcome. The presence of HPV DNA was evaluated using in situ hybridization on formalin‐fixed, paraffin‐embedded tissue sections. Eighty‐five patients with cervical carcinoma who had been surgically evaluated were included in the study. Data from these patients was analyzed retrospectively to determine survival, recurrence, presence of nodal metastases, tumor grade, mode of therapy, peritoneal fluid cytologic results, and age in relation to presence or absence of HPV DNA. No significant statistical differences were found between the HPV‐16‐positive, HPV‐18‐positive, and HPV DNA‐negative patients.

Role of whole abdominal radiation therapy in the management of endometrial cancer; prognostic importance of factors indicating peritoneal metastases

From 1973 through 1983, 27 women received postoperative open-field external beam abdominal radiotherapy as primary treatment of endometrial carcinoma. The 5-year survival rate was 71%. Two distinct prognostic groups were demonstrated. Patients with spread to the adnexa, peritoneal fluid, or both, had a 5-year relapse-free rate of 90%. Patients with macroscopic spread of cancer beyond the adnexa had a 5-year relapse-free rate of 0%. Guidelines are suggested for the radiotherapeutic management of endometrial cancer metastatic to the peritoneal cavity.

Adenosquamous carcinoma of skin appendages (adenoid squamous cell carcinoma, pseudoglandular squamous cell carcinoma, adenoacanthoma of sweat gland of lever) of the vulva. A clinical and ultrastructural study

History and clinical findings of 18 cases of adenosquamous carcinoma of the skin appendages found among 135 cases of primary carcinoma of the vulva seen at the University of Minnesota Hospitals between 1951 and 1970 were analyzed. In addition, two recent cases of this tumor were studied with conventional transmission electron microscopy. Adenosquamous carcinoma of the vulva showed poorer survival and a higher rate of lymph node metastases than squamous cell carcinoma of the corresponding stages (carcinoma in situ excluded). In four out of thirteen cases, the metastatic lesions in the lymph nodes retained glandular pattern. The ultrastructure showed mucin‐producing columnar cells lining glandular lumina, and poorly differentiated squamous cells elsewhere; further, cells of the intermediate type between the two were present. This study indicates that adenosquamous carcinoma of the vulva is a distinctively separate entity from squamous cell carcinoma of the vulva, and possibly arises from mucin‐producing cells of the skin appendages as suggested by Johnson and Helwig. Cancer 42:1851‐1858, 1978.

Therapeutic implications of the natural history of advanced cervical cancer as defined by pretreatment surgical staging

From 1978 to 1983, 112 women with advanced cervical carcinomas received radiotherapy after pretreatment surgical staging. Five‐year actuarial relapse‐free survival rates were a strong function of lymphatic spread: 40% with periaortic node metastases, 50% with pelvic node metastases, and 84% without node metastases. Primary treatment failure had a distant component in 75% of recurrences (50% of recurrences with negative nodes and 85% of recurrences with positive nodes). It was concluded that adjuvant systemic therapy is necessary to substantially raise the probability of cure.

Primary malignant melanoma of the vagina: A clinicopathological analysis of 10 cases

We retrospectively analyzed clinicopathological findings in 10 cases of primary malignant melanoma of the vagina. The main presenting symptoms were vaginal bleeding, vaginal discharge, and feeling of a mass. The tumors were predominantly located in the lowest one-third and in the anterolateral aspect of the vagina. Patients underwent various surgical procedures, radiation therapy, and chemotherapeutic modalities. The mean survival time and the recurrence time from the time of diagnosis were 15 and 8 months, respectively. The tumors were examined for histological characteristics of cell type, presence of melanin pigment, depth of invasion, vascular invasion, intraepithelial spread, junctional activity, and mitotic count. Of all these histological variables, the mean survival time had a significant correlation to mitotic count (P less than 0.04). We concluded that patients with lower mitotic counts (less than 6 per 10 HPF) had better survival (21 months) compared to patients with mitotic counts greater than 6 per 10 HPF who had a mean survival of only 7 months.

Cytoplasmic estrogen and progesterone receptors in primary cervical carcinoma: Clinical and histopathologic correlates

From 1977 to 1981, 39 cases of primary cervical carcinoma were assayed for the presence or absence of cytoplasmic estrogen (ERc) and progesterone (PRc) receptors by a saturation point dextran-coated charcoal assay. The levels of ERc and PRc were compared with clinical stage, histologic type, histologic grade, menstrual status, age, and survival. Carcinomas were divided into positive and negative receptor groups with the use of greater than 5 fmol/mg of cytosol protein for ERc and 10 fmol/mg of cytosol protein for PRc as discrimination points. Survival of the patients studied was computed by means of the product-limit analysis according to Kaplan-Meier. A statistically significant difference in survival in the PRc + group versus the PRc - group in the total group of patients was noted with the Mantel-Cox test (P = 0.049). When patients were stratified according to menopausal status, a statistically significant difference in survival was noted between the PRc + group versus the PRc - group in the premenopausal patients only.

Prognostic importance of progesterone and estrogen receptors in cancer of the uterine cervix

Tissue levels of cytosolic estrogen receptors (ERc) and progesterone receptors (PRc) have been shown to have prognostic meaning in hormonally responsive cancers arising in the breast and endometrium. Although carcinomas of the uterine cervix rarely respond to hormonal manipulation, the normal cervical stroma and epithelia contain ERc and PRc. To study the prognostic value of these receptors, 65 cervical carcinomas for ERcand PRcwere assayed before initiation of surgical or radiation therapy. In premenopausal women, logistic models demonstrated that clinical stage, surgical stage, and receptor level independently predict survival. If confirmed in further studies, ERc and PRc may prove to be useful prognostic factors in the management of cervical carcinomas.

Logistic models for prediction of enteric morbidity in the treatment of ovarian and cervical cancers

To identify patients at high risk for the development of enteric injury, an analysis was made of 212 women who received extensive pelvic and abdominal radiotherapy at the University of Minnesota from 1970 through 1981. One hundred one patients with cervical carcinomas received 8,000 to 8,500 rads to point A, 6,000 rads to point B, and 4,500 to 5,075 rads to the periaortic lymph nodes. One hundred eleven women with ovarian cancers received 2,000 rads to the entire abdomen, followed by an additional 2,975 to 3,000 rads to the pelvis. The overall complication rate was 6.6% (14/212). The only patients who sustained chronic radiation morbidity had thin physiques. The maximum likelihood multiple logistic model was utilized to predict the probability of enteric injury as a function of thin physique, previous operations, and hypertension for individual patients. The usefulness of predictive models is discussed, and possible reasons for the susceptibility of thin women to ionizing radiation are explored.