Michael P. Stany

The impact of disease distribution on survival in patients with stage III epithelial ovarian cancer cytoreduced to microscopic residual: A gynecologic oncology group study

OBJECTIVE To assess the survival impact of initial disease distribution on patients with stage III epithelial ovarian cancer (EOC) cytoreduced to microscopic residual. METHODS We reviewed data from 417 stage III EOC patients cytoreduced to microscopic disease and given adjuvant intravenous platinum/paclitaxel on one of three randomized Gynecologic Oncology Group (GOG) trials. We subdivided patients into three groups based on preoperative disease burden: (1) minimal disease (MD) defined by pelvic tumor and retroperitoneal metastasis (2) abdominal peritoneal disease (APD) with disease limited to the pelvis, retroperitoneum, lower abdomen and omentum; and (3) upper abdominal disease (UAD) with disease affecting the diaphragm, spleen, liver or pancreas. We assessed the survival impact of potential prognostic factors, focusing on initial disease distribution using a proportional hazards model and estimated Kaplan-Meier survival curves. RESULTS The study groups had similar clinicopathologic characteristics. Median overall survival (OS) was not reached in MD patients compared to 80 and 56 months in the APD and UAD groups (P<0.05). The five-year survival percentages for MD, APD, and UAD were 67%, 63%, and 45%. In multivariate analysis, the UAD group had a significantly worse prognosis than MD and APD both individually and combined (Progression Free Survival (PFS) Hazards Ratio (HR) 1.44; P=0.008 and OS HR 1.77; P=0.0004 compared to MD+APD). CONCLUSION Stage III EOC patients with initial disease in the upper abdomen have a worse prognosis despite cytoreductive surgery to microscopic residual implying that factors beyond cytoreductive effort are important in predicting survival.

BENIGN DISORDERS OF THE OVARY

Most ovarian disorders are benign, with the majority being functional ovarian cysts and benign neoplasms. Imaging can often aid in diagnosis and risk assessment. Benign ovarian disorders are frequently incidental findings, but they may cause symptoms from hormonal overproduction, mass effects, or torsion. In addition to symptoms, any ovarian abnormality can raise the specter of malignancy. Knowledge of the cause, presentation, and natural history of these benign ovarian disorders helps providers counsel and treat patients appropriately.

A clinicopathologic study of vaginal intraepithelial neoplasia.

OBJECTIVE: To evaluate the natural history of vaginal intraepithelial neoplasia (VAIN) and to identify risk factors for invasive vaginal carcinoma. METHODS: The records of all women with VAIN diagnosed at military treatment facilities over a 10-year period with minimum follow-up of 12 months were reviewed. Patient demographics and clinical information related to the diagnosis and treatment of VAIN were recorded. RESULTS: One hundred twenty-seven women with VAIN met inclusion criteria. The mean age was 47.4 years, and median surveillance was 34 months (range 12–169 months). Seventy-five patients had low-grade vaginal dysplasia as their initial diagnosis, and 15 (20%) of these patients underwent treatment. Fifty-two patients had high-grade vaginal dysplasia, of which 38 (73%) underwent treatment. Overall, 113 patients (89%) demonstrated normalization of disease, 11 patients (9%) demonstrated persistence of disease, and three patients (2%) experienced recurrence of disease. No patients experienced development of invasive vaginal carcinoma. However, median time to normalization was 6 months longer in patients with low-grade dysplasia compared with those with high-grade dysplasia (15.9 months compared with 10.0 months; hazard ratio 1.5; 95% confidence interval 1.004–2.1; P=.045). Patients with high-grade dysplasia had more biopsies performed during their surveillance than patients with low-grade dysplasia (3.3 compared with 2.5; P=.045). CONCLUSION: Overall, 89% of patients demonstrated normalization of VAIN, and none had progression to invasive cancer. Normalization, persistence, and recurrence rates did not significantly differ by grade of dysplasia or treatment status. Based on our findings regarding the time to normalization, annual surveillance with combined cytology and colposcopy is likely adequate. Because 11% of patients with VAIN either will experience recurrence or will have persistent disease, lifetime surveillance is recommended. LEVEL OF EVIDENCE: III

Clinical Decision Making Using Ovarian Cancer Risk Assessment

OBJECTIVE Although any adnexal abnormality found at imaging can be concerning for an ovarian malignancy, the clinician must perform an evaluation to decide if the actual likelihood of malignancy justifies the risk of surgery. When determining the likelihood of an asymptomatic, incidental adnexal mass being malignant, the provider must answer one important question: Do the clinical findings warrant the potential morbidity of surgery? This article will focus on the decision making that goes into such an evaluation. CONCLUSION A patients medical history, physical examination, CA-125 level, and imaging characteristics are all factors that impact the ultimate decision of whether a patient can be observed with repeat imaging or should proceed to surgical evaluation.

Gemcitabine-associated large vessel vasculitis presenting as fever of unknown origin.

Gemcitabine is a nucleoside analogue used for treatment of multiple cancers. Recent reports describe small to medium vessel vasculitis as a rare complication of therapy. We report a case of significant large vessel vasculitis presenting as fever of unknown origin in a patient treated adjuvantly with docetaxel and gemcitabine for uterine leiomyosarcoma.The patient presented after her first and second exposure to chemotherapy with fever of unknown origin and worsening subsequent chest and neck discomfort. Extensive workup revealed radiographic and laboratory evidence of aortic vasculitis. We initiated treatment with high-dose corticosteroids, and the patients condition resolved without complication over the next several weeks.To our knowledge, this represents the first case of gemcitabine-induced large vessel vasculitis which presented in our case as fever of unknown origin. Awareness of this potential complication is essential as discontinuing the inciting drug and initiating corticosteroid treatment can be life-saving.

Incidental gynecological findings on computed tomographic colonography: Prevalence and outcomes

OBJECTIVES Computed tomographic colonography (CTC) is an investigational method for detecting colorectal polyps. Our objectives were to determine the prevalence of gynecologic findings found incidentally on CTC, and to determine the incidence of additional radiological studies and surgical procedures. METHODS An electronic database identified female patients who underwent CTC at Walter Reed Army Medical Center from January 2002 to July 2005. CTC reports were pared down using gynecologic keywords. Subsequent radiological studies and pathology reports were evaluated for women with gynecological findings. RESULTS Gynecologic extracolonic findings (ECF) were identified in 71 (9.5%) of the 749 women who underwent CTC. Of these 71 women, 14 (20%) underwent additional radiological and/or surgical evaluation. Nine (13%) of these women underwent surgical evaluation; all pathologic diagnoses were benign. CONCLUSION Gynecologic extracolonic findings are common in women undergoing CTC. These gynecologic ECF identified on CTC may lead to additional investigative studies and procedures.

The use of acellular dermal allograft for vulvovaginal reconstruction.

Background: Many different techniques that require the surgeon to harvest autologous tissue to create a neovagina have been described in the literature. Technique: We describe a technique for creating a neovagina with the use of an acellular dermal allograft as a replacement for split-thickness skin graft. Three patients are presented who had a successful creation of a neovagina with this technique. The indications for vaginoplasty include vaginal agglutination from lichen planus, squamous cell carcinoma of the vagina, and vaginal agenesis. Conclusion: The creation of a neovagina using an acellular dermal allograft can be successfully accomplished in patients undergoing constructive and exenterative procedures. The use of an acellular dermal allograft decreases operative time and decreases the incidence of postoperative morbidity because harvesting autologous tissue for the neovagina is not required.

The use of acellular dermal graft for vulvovaginal reconstruction in a patient with lichen planus.

BACKGROUND: Vulvovaginal lichen planus is an inflammatory dermatosis that can progress to an erosive form with scarring of the vulva, resorption of the labia minora, vaginal synechiae, and vaginal obliteration secondary to desquamative vaginitis. Traditionally, conservative medical therapy has consisted of topical corticosteroids and immunosuppressants. CASE: A 61-year-old woman with a history of refractory erosive vulvovaginal lichen planus presented with complete obliteration of the vaginal vault. The patient failed both medical and conservative surgical management and desired definitive management. After performing a skinning vulvectomy and simple vaginectomy, acellular dermal graft was used for grafting the vulva and creating a neovagina. CONCLUSION: Acellular dermal graft is a suitable graft material for vulvar and vaginal reconstruction in select patients, and it avoids the postoperative pain associated with graft harvest sites.

Does Routine Posttreatment PET/CT Add Value to the Care of Women With Locally Advanced Cervical Cancer?

Objectives The aim of this study was to determine the necessary reduction in recurrence rate that would make postchemoradiation positron emission tomography (PET)/computed tomography (CT) to direct completion hysterectomy for locally advanced cervical cancer (LACC) cost-effective. Methods A decision model evaluated costs and recurrence rates of 2 posttreatment surveillance strategies in LACC: (1) routine surveillance without PET/CT and (2) PET/CT after 3 months to triage to completion hysterectomy. Incremental cost-effectiveness ratios were expressed in dollars per additional cancer recurrence avoided. Model parameters included expected rates of recurrence using each strategy, true- and false-positive rates of posttreatment PET/CT, and major complications of completion hysterectomy. From published data, we modeled an LACC baseline recurrence rate of 32%, PET/CT false-positive rate of 33%, and false-negative rate of 19%. We assumed that PET/CT revealed persistent local cervical cancer in 16% and progressive or distant disease in 6%. Costs of PET/CT, hysterectomy, and treatment for recurrence were based on Medicare reimbursements. A 50% salvage rate with hysterectomy was assumed and varied in sensitivity analysis. Results Routine use of PET/CT to direct completion hysterectomy was associated with a higher average cost (

The prevalence of HR-HPV DNA in ASC-US Pap smears: A military population study☆

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