Michael A. Finan

Upper vaginectomy for in situ and occult, superficially invasive carcinoma of the vagina

Between Aug. 1, 1985, and July 31, 1990, 32 patients underwent upper vaginectomy for grade 3 vaginal intraepithelial neoplasia. Thirty-one of these patients had undergone hysterectomy, 25 because of cervical neoplasia. Fourteen patients had undergone treatment for vaginal intraepithelial neoplasia. Nine (28%) had invasive cancer on final pathologic examination. Among the remaining 23 patients, recurrence of vaginal neoplasia developed in four (17%), with a mean time to recurrence of 78 weeks, and one was found to have superficial invasion at the time of recurrence. The remaining 19 patients remain alive with no evidence of recurrent disease at a mean follow-up interval of 152 weeks. In our patients upper vaginectomy was efficacious for the diagnosis of occult invasive carcinoma of the vagina and for the treatment of in situ and superficially invasive carcinoma of the vagina.

Further experience with radiation therapy and concomitant intravenous chemotherapy in advanced carcinoma of the lower female genital tract.

Sixty-seven patients with advanced carcinoma of the lower female genital tract (cervix, vagina, and vulva) were treated with radiation and concomitant intravenous cisplatin and/or 5-fluorouracil. Fifty-seven patients (85%) responded completely clinically. Thirty-five (61%) complete responders recurred with a median time to recurrence of 6 months. Twenty-six of the thirty-five patients who recurred had some component of local failure. The 22 complete responders who have not recurred have been followed a median of 13 months. Acute toxicity was minimal, with only 6 patients requiring interruption of therapy. Nine (13%) patients developed severe late complications and eight required surgery. The actuarial 5-year survival is 22%. This treatment regimen is disappointing in terms of both survival and local control.

Lymphoscintigraphy in vulvar cancer: a pilot study.

Abstract This pilot study was undertaken to correlate the patterns of lymphatic drainage demonstrated by vulvar lymphoscintigraphy with the clinical and pathologic findings of the inguinofemoral lymph nodes in patients with vulvar cancer. Ten patients were studied with the radionuclide Technetium-antimony trisulfide colloid (Tc 99m ASC) using a perilesional technique. Images were obtained at 2–4 hr postinjection. Four of the six patients with central lesions or lesions that crossed the midline had bilateral groin uptake, and two had unilateral uptake to the side on which the lesion was predominantly located. Three of these patients, each with suspicious groin nodes bilaterally, had metastatic nodal disease, two unilateral and one bilateral, in whom the uptake was bilateral and unilateral, respectively. Three of the four patients with unilateral lesions had ipsilateral groin drainage only and one had no drainage. Three underwent a bilateral lymphadenectomy and none had metastasis. The pattern of Tc 99m ASC uptake was not predictive of metastatic nodal disease. In two of the three patients with unilateral groin recurrence the side of recurrence was the same as that demonstrated on lymphoscintigraphy, and in the third case there was bilateral drainage. Further data are needed to determine the role of lymphoscintigraphy in the management of vulvar cancer.

A comparative study of radical vulvectomy and modified radical vulvectomy for the treatment of invasive squamous cell carcinoma of the vulva

Forty-five patients who underwent a modified radical vulvectomy for invasive squamous cell carcinoma of the vulva were compared with forty-five patients who underwent radical vulvectomy for similar lesions. Vulvar wound infection and breakdown were infrequent in both groups. Anal incontinence developed postoperatively in five of the modified radical vulvectomy patients and in none of the radical vulvectomy patients. Urinary incontinence developed postoperatively in two of the modified radical vulvectomy patients and in seven of the radical vulvectomy patients. Possible reasons for these differences are discussed. One invasive local recurrence (2.2%) developed in the modified radical vulvectomy group and two (4.4%) local recurrences developed in the radical vulvectomy group. A modified radical vulvectomy appears to be efficacious for the vulvar phase of treatment of localized invasive squamous cell carcinoma of the vulva.

Complications of colostomy performed on gynecologic cancer patients

From 1/1/80 to 5/31/90 111 patients underwent a colostomy on a gynecologic oncology service. Six patients developed 7 (6.3%) early colostomy-related complications, including sepsis (1), stomal retraction (1), ostomy wound infection (3), and partial stomal obstruction (2). The sepsis was felt to be related to spillage of stool upon maturing the colostomy, and this patient expired on Postoperative Day 63. There were no other mortalities attributed to the colostomies. Fourteen patients developed 17 (15.3%) delayed colostomy-related complications, including parastomal hernia (5), stomal retraction (1), stomal prolapse (3), tumor replacement (2), and site-choice problems (6). These results compare favorably with those in the literature and support the continued role of the gynecologic oncologist in gynecologic cancer-related gastrointestinal surgery.

The effects of cold therapy on postoperative pain in gynecologic patients : a prospective, randomized study

Objective: The purpose of the study was to determine the effect of cold therapy on the subjective assessment of pain, analgesic requirements, and wound complications in female patients undergoing major abdominal surgery. Study Design: Twenty-seven patients were entered in the study in a prospective, randomized fashion. The Hot/Ice Thermal Blanket was applied to 13 patients, and 12 patients were in the control group. All patients underwent exploratory laparotomy and received postoperative pain relief with intravenously self-administered morphine sulfate through a patient-controlled analgesic pump. Results: Compared with the control group (0.363 ± 0.118 mg/kg/day), the cold pack group used more morphine sulfate on the first postoperative day (0.529 ± 0.236 mg/kg/day, p Conclusion: We conclude that the cold pack does not improve postoperative pain control in gynecologic patients undergoing exploratory laparotomy.

Postoperative ileus on a gynecologic oncology service: do abdominal X-rays have a role?

OBJECTIVE The objective was to estimate the role of abdominal radiographs in the management of the patient with gastrointestinal dysfunction in the early postoperative period following intra-abdominal gynecologic surgery. METHODS Hospital records were reviewed for 84 patients from the gynecologic oncology service having a clinical diagnosis of either ileus or bowel obstruction immediately after intra-abdominal gynecologic surgery. Patient history, clinical signs and symptoms, findings of plain radiographs, and clinical course were studied to determine whether plain abdominal radiographs were useful in the management of these patients. RESULTS At least one set of abdominal X-rays was obtained for 56 (66.7%) patients, of which 24 (42.9%) were considered radiographically diagnostic. A lower preoperative American Society of Anesthesiologists (ASA) physical status score correlated with a greater likelihood of having abdominal films (P = 0.005). No single clinical finding correlated with either the decision to obtain films or X-ray diagnosis of ileus or bowel obstruction. Use of any nonsurgical treatment modality was not significantly different for patients who had films versus those who did not. Mean length of hospital stay was significantly prolonged for patients who had abdominal X-rays. Seven patients were subjected to reoperation; however, no association was found between X-ray diagnosis of ileus or bowel obstruction and the need for reoperation. CONCLUSION Plain abdominal radiographs have little clinical utility in the evaluation of patients with gastrointestinal dysfunction in the early postoperative period following intra-abdominal gynecologic surgery. Diagnostic studies such as CT scanning or a GI contrast study may be more helpful in the management of these patients.

Body mass predicts the survival of patients with new international federation of gynecology and obstetrics stage IB1 and IB2 cervical carcinoma treated with radical hysterectomy

The authors evaluated the impact of body mass on survival and morbidity of patients with new International Federation of Gynecology and Obstetrics (FIGO) Stage IB1 and IB2 cervical carcinoma managed with radical hysterectomy.

Ultraradical surgery for advanced carcinoma of the vulva: an update

From July 1, 1955 to March 31, 1989 24 patients with locally advanced vulvar cancer underwent ultraradical resection. Three patients had received prior radiotherapy. Seventeen of the 24 patients underwent posterior exenteration, four underwent anterior exenteration, and the remaining three required a total pelvic exenteration. One patient died 3 months postoperatively of fulminating infection considered to be a complication of the operation. Three other patients experienced serious complications, including postoperative hemorrhage, severe urinary sepsis, and colostomy stoma necrosis. Eleven (46%) of the 24 patients have remained alive without evidence of recurrent cancer for at least 3 years. Of the 10 patients known to have died of recurrent cancer, nine had positive lymph nodes at the time of surgery. It may be reasonable to utilize ultraradical surgery in patients with clearly resectable lesions who have negative or perhaps 1 or 2 microscopically positive regional lymph nodes.

Use of local flaps in the preservation of fecal continence following resection of perianal neoplasias.

The feasibility of achieving curative resection of perianal pre-invasive and invasive lesions with preservation of fecal continence was studied prospectively. Resection of these lesions involved excision of as much as the anterior third of the external anal sphincter. Twenty-two patients had invasive cancer and nine had extensive carcinoma in situ suspicious for invasive disease on preoperative assessment. Anal reconstruction consisted of plication of the external anal sphincter and plication of the puborectalis muscles. The perianal/perineal defects were closed using bilateral rhomboid flaps in 21 patients, unilateral rhomboid flaps in five patients and local advancement flaps in five patients. Twenty-eight patients were ultimately continent of feces, although two required further surgery for incontinence. Two of the three incontinent patients had fecal incontinence before surgery. Two patients had recurrence of invasive cancer, neither of which was perineal or perianal. Curative surgery of selected perianal lesions with preservation of fecal continence can be achieved with local resection and reconstruction with the use of local full thickness skin flaps.