Steven L. DeCesare

Accuracy of lymph node palpation to determine need for lymphadenectomy in gynecologic malignancies.

Objective To assess the accuracy of intraoperative lymph node palpation for identifying lymph node metastasis in gynecologic malignancies. Methods We prospectively evaluated 126 women who had lymphadenectomies for staging of various gynecologic malignancies from August 1995 to June 1997. Surgeries were done by obstetrician-gynecologists with subspecialty certification in gynecologic oncology from the American Board of Obstetrics and Gynecology, who had practiced gynecologic oncology for at least 5 years. Data were collected on gynecologic oncologists opinions of lymph node status by palpation. Nodes believed to be positive were sent separately. We recorded operating time for lymphadenectomies, and intraoperative and postoperative complications. Results Mean (range) patient age was 55 (18–83) years. Mean (range) operating time was 188 (85–435) minutes. The mean (range) lymphadenectomy time was 46 (5–150) minutes. The total number of lymph nodes dissected was 2138. One hundred seven of 2138 (5%) nodes were positive for malignancy. Thirty-eight of 107 (36%) positive lymph nodes were missed by palpation. Fifty-six of 2031 (3%) negative lymph nodes were selected as positive. Sixty-nine of 107 (64%) positive lymph nodes were identified correctly. Sensitivity and specificity of palpation were 72% and 81%, respectively. The positive and negative predictive values of lymph node palpation were 56% and 89%, respectively. Conclusion Intraoperative lymph node palpation has low sensitivity and positive predictive value even when done by experienced board-certified gynecologic oncologists.

Abdominal hysterectomy versus transvaginal morcellation for the removal of enlarged uteri

OBJECTIVEnThe purpose of this study was to compare the intraoperative and postoperative complications of transvaginal morcellation and abdominal hysterectomy for the removal of moderately enlarged uteri.nnnSTUDY DESIGNnAn observational study was performed on all uteri weighing > 200 gm removed transvaginally from July 1, 1987, to June 30, 1993. An abdominal hysterectomy control group was selected.nnnRESULTSnThere were 50 patients in the vaginal group and 112 in the abdominal group. At a p value < 0.05 there was no statistically significant difference between the two groups for age, parity, obesity, hypertension, insulin-dependent diabetes mellitus, or prior genitourinary surgery. The mean operative time in the vaginal hysterectomy group was 122 minutes and in the abdominal hysterectomy group 148 minutes (p < 0.05). The mean estimated blood loss was 527 and 586 ml, respectively (not significant). Twenty-two percent of the vaginal group and 70% of the abdominal group underwent bilateral oophorectomy (p < 0.05). The mean uterine weights were 335 and 336 gm, respectively (not significant). The mean day of starting a regular diet was 2.1 and 3.6, respectively (p < 0.05). The mean day of discharge was 3.6 and 5.1, respectively (p < 0.05). Complications were similar for the two groups.nnnCONCLUSIONSnIn selected patients transvaginal morcellation is a safe and effective alternative to abdominal hysterectomy for the removal of moderately enlarged uteri. The two procedures are comparable in operative time, blood loss, and complications. Both ovaries are more likely to be removed with abdominal hysterectomy. Cosmesis and recuperation may be advantages of the vaginal approach.

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.

Interleukin-12 synergizes with interleukin-2 to generate lymphokine-activated killer activity in peripheral blood mononuclear cells cultured in ovarian cancer ascitic fluid.

Objective: The ascites-associated lymphocytes in ovarian cancer have altered immunologic function, and cell-free ascitic fluid has immunomodulating properties. We determined (1) whether interleukin (IL)-2 could induce lymphokine-activated killer (LAK) activity in normal peripheral blood mononuclear cells (PBMC) cultured in ovarian cancer ascitic fluid, and (2) whether IL-12 could synergize with IL-2 to generate LAK activity in normal PBMC cultured in ascitic fluid. Methods: Normal PBMC were cultured in control medium and in media consisting of 50% ascitic fluid (ascitic medium), with and without IL-2 and LI-12. Cell activation to assess LAK activity (cell lysis) was determined in a 51Cr-release assay with the tumor cell lines FMEX and SKoV3 as target cells. To determine a possible mechanism for any synergistic effect, the expression of perforin, a pore-forming protein, was determined by Northern blot analysis. Results: Interleukin-2 alone could not induce LAK activity in normal PBMC cultured in 50% ascitic fluid for up to 3 days. Interleukin-12 did mediate some or minimal LAK activity after 1, 2, or 3 days of incubation in control medium or in 50% ascitic fluid. When IL-2 and IL-12 were used in combination, PBMC cultured for 3 days in 50% ascitic fluid had remarkably high lytic activity against FMEX and SKOV3 tumor cells. In some experiments, this cytotoxicity was greater than that in PBMC cultured in control medium with IL-2 and IL-12. Lower concentrations of IL-12 (1 U/mL) with IL-2 (100 U/mL) were as effective as, and often more effective than, higher doses of IL-12 with IL-2. Very low-dose IL-12 (0.01-0.03 U/mL) in combination with IL-2 also induced a range of cytotoxicities. Only the combination of IL-2 and IL-12 up-regulated expression of perforin mRNA in ascitic medium. Conclusions: The cytotoxicity responses of PBMC cultured in ascitic fluid in the presence of IL-2 and IL-12 are complex. Low-dose IL-2 and IL-12 can overcome the inhibitory property of ascitic fluid on LAK generration and can restore and enhance cytotoxic activity, possibly by reconstituting the expression of perforin. These findings may have therapeutic potential.

The Accuracy of Frozen Section Pathology in the Staging of Endometrial Cancer: A Retrospective Study [12P]

INTRODUCTION: Endometrial cancer is the most common gynecologic malignancy in the United States. Endometrial cancer treatment and prognosis is dependent on the severity and spread of disease. In order to determine severity and spread we depend upon surgical staging and pathologic evaluation including intra-operative frozen section (IFS) and permanent section (PS). METHODS: A retrospective chart analysis between Jan 2013–Dec 2014 of patients diagnosed with endometrial cancer after permanent pathologic evaluation. Exclusion criteria: no frozen section, previous pelvic radiation, clinically advanced disease, coexisting second malignancy, and uterine sarcoma. Chi square analysis of IFS vs PS grade, histologic type, and depth of invasion of tumor. The primary outcome was to determine the accuracy of intraoperative frozen section to permanent section pathology in patients with endometrial cancer. RESULTS: There were 111 cases of endometrial cancer identified between Jan2013–Dec 2014. Of these a total 68 pts analyzed after exclusion criteria. Using IFS to identify lower risk disease prior to performing comprehensive staging can be beneficial to reduce these risk. IFS histologic type was strongly correlated to PS with a P value of <.0001. IFS depth of invasion was strongly correlated to PS a P value of <.0001. CONCLUSION: Using IFS to identify lower risk disease prior to performing comprehensive staging can be beneficial. IFS accurately identifies grade, histologic type, and depth of invasion of endometrial cancer when compared to PS at this institution. IFS can be used as a resource for gyn oncologists to determine whether to proceed with comprehensive staging.

A Pilot Study Utilizing Intraoperative Lymphoscintigraphy for Identification of the Sentinel Lymph Nodes in Vulvar Cancer

OBJECTIVEnTo identify sentinel lymph nodes using intraoperative lymphoscintigraphy.nnnMETHODSnTechnetium-99-labeled sulfur colloid was injected at the site of primary vulvar carcinoma. An intraoperative gamma counter was used to identify one or more sentinel lymph nodes.nnnRESULTSnTen patients underwent bilateral inguinal and femoral lymphadenectomy. The clinical stages are as follows: T1 in 6, T2 in 2, and T3 in 2. A total of four groins (3 patients) were positive for metastases. In one patient only the sentinel node was positive for disease. In a second patient, two unilateral nodes were positive for disease and both were identified with the gamma counter as sentinel nodes. In the third patient, a single sentinel node was positive for malignancy in each groin. Multiple nonsentinel lymph nodes were positive in each groin in this patient. In no case was the sentinel node negative when other nonsentinel nodes were positive.nnnCONCLUSIONnIntraoperative lymphoscintigraphy quantitatively identifies one or more sentinel lymph nodes. Since sentinel lymph nodes can be localized transcutaneously, this technique may be useful for selective lymphadenectomy. Larger patient accrual is necessary to verify this technique.