Younes N. Bakri

Malignant germ cell tumors of the ovary. Pregnancy considerations.

OBJECTIVE To study the pregnancy association and malignant germ cell tumors of the ovary with regard to its effects on tumor prognosis. STUDY DESIGN : Seventy-five patients with malignant germ cell tumors of the ovary treated at the King Faisal Specialist Hospital-Research Center (KFSH-RC) Riyadh, Kingdom of Saudi Arabia between January 1976 and December 1992, were reviewed. Data was retrieved from the medical records and the database of ovarian tumor pathology. Patients with tumor/pregnancy association were identified and correlation with obstetrical outcome and tumor prognosis analyzed. Patients who conceived after treatment were identified and their reproductive outcome described. RESULTS Malignant germ cell tumor was associated with pregnancy in a group of ten patients. Possible tumor effects upon pregnancy in this group included operative delivery by caesarean section (n=3), mid-trimester termination (n=2), spontaneous abortion (n=1). Four patients had normal vaginal birth with no apparent tumor effects upon pregnancy. Pregnancy did not seem to influence the tumor prognosis of pure dysgerminoma (n=6), however, two patients with non-dysgerminomatous germ cell tumor (one endodermal sinus tumor and one immature teratoma) died of rapidly progressive disease during the second trimester. Two patients with advanced (stage IIIC) disease concurrent with pregnancy (one pure dysgerminoma and one mixed germ cell tumor), had normal fetal outcomes and achieved long-term survival. Amongst the 22 patients who planned to conceive after conservative surgery, with or without post-operative adjuvant chemotherapy, 12 conceived (12/22) and achieved a total of 20 pregnancies. Their outcomes included normal births (n=18) including one set of twins and hydatidiform moles (n=2). CONCLUSIONS Our findings suggest that, (1) The association of pure dysgerminoma and pregnancy did not adversely affect the tumor prognosis or fetal outcome. However, the question remains as to whether pregnancy worsened the prognosis of non-dysgerminomatous germ cell tumors. (2) Recent platinum-based regimens of multiagent chemotherapy for germ cell tumors did not seem to affect fertility potential.

Placenta previa-percreta : magnetic resonance imaging findings and methotrexate therapy after hysterectomy

A case is reported of a 42-year-old woman with placenta previa-percreta and multiple previous cesarean sections. Preoperative magnetic resonance imaging findings are described. Management included a cesarean supracervical hysterectomy, bilateral hypogastric arterial ligation, and intraoperative methotrexate administration. The placental portion that invaded the urinary bladder wall was left in place, without attempt to remove it surgically.

Normal pregnancy and delivery following conservative surgery and chemotherapy for ovarian endodermal sinus tumor.

Management of younger patients with early stage ovarian endodermal sinus tumor who desire to have children can be a challenging problem. However, after an adequate and thorough staging procedure for the patients tumor status, a Stage Iai endodermal sinus tumor may be treated with conservative surgery only, followed by chemotherapy. Successful pregnancy and delivery following unilateral adnexectomy and chemotherapy for ovarian endodermal sinus tumor have been reported only once [J. P. Forney, Obstet. Gynecol. 52, 360 (1977)]; the second reported case is presented here. It should be pointed out that strict follow-up and reliability of the patient are mandatory for such conservative therapy.

Complications from intraperitoneal radioactive phosphorus in ovarian malignancies

A retrospective study of the use of phosphorus-32 in the treatment of 73 cases of ovarian malignancy to evaluate the safety and morbidity is presented. The surgically confirmed major complication rate with P-32 alone was 4 of 54 cases (7.4%). The addition of external radiation raised the surgically confirmed complication rate to 4 of 19 cases (21%) and with the addition of those diagnosed and treated only medically the rate rose to 8 of 19 cases (42%). In Stage I cases, Grades 1 and 2, there was only 1 death in 26 patients (96%), whereas for Grade 3 tumors only 6 of 12 patients (50%) were living at the end of 2 years.

Vulvar sarcoma: A report of four cases

The clinical profiles of four patients with primary vulvar sarcomas are presented. Two patients had leiomyosarcoma in association with pregnancy, a third patient had a leiomyosarcoma with epithelioid elements, and a fourth had alveolar rhabdomyosarcoma. The natural history of the disease in the three leiomyosarcomas (including the case with epithelioid elements) was characterized by an indolent protracted course and frequent local recurrence, followed by distant fatal metastases. The patient with alveolar rhabdomyosarcoma is alive-with-disease. Surgery, chemotherapy, and radiotherapy achieved palliation rather than cure. Pregnancy did not seem to influence the prognosis.

Neuroleptic malignant syndrome associated with metoclopramide antiemetic therapy

A case of neuroleptic malignant syndrome in a 50-year-old woman with ovarian cancer is reported. The syndrome was associated with metoclopramide antiemetic therapy given for post-operative nausea and vomiting. Dantrolene, bromocriptine, and supportive measures were effective in obtaining a complete resolution of the syndrome. This potentially lethal syndrome is perhaps underreported in the gynecologic literature. Heightened awareness of its signs and symptoms may cause more cases to be recognized and help improve its outcome.

Radioactivity in blood and urine following intraperitoneal instillation of chromic phosphate in patients with and without ascites

Systemic distribution of radioactive colloidal chromic phosphate P 32 after intraperitoneal instillation was studied in 10 patients with ovarian or endometrial malignancies. Seven patients without ascites received chromic phosphate P 32 for positive peritoneal washings, rupture of the capsule of the cyst during operation, or minimal Stage III disease. Three patients received chromic phosphate P 32 for recurrent ascites after multiple abdominal paracenteses. Blood and urine radioactivity measurements were performed at selected intervals. There was a clear statistically significant difference (p less than 0.01) between chromic phosphate P 32 activity levels in whole blood, red blood cells, and plasma in patients with and without ascites.

Uterine choriocarcinoma with negative specific serum radioimmunoassay for human chorionic gonadotropins

Abstract A case of uterine choriocarcinoma complicating gestational trophoblastic disease is presented. Following chemotherapy, there seemed to be an apparent cure as indicated by follow-up monitoring of the beta subunit of human chorionic gonadotropin (B-HCG assay) when the assay demonstrated three consecutive weekly negative results. At the same period when the assays were negative, the patient was manifesting irregular vaginal bleeding for which diagnostic D&C was done revealing persistant disease which was not detected by measurement with the sensitive quantitiative B-HCG assay. The case is discussed to confirm the fact that clinical assessment is necessary for the follow-up of trophoblastic disease in addition to quantitative B-HCG.

CARCINOMA OF THE UTERINE CERVIX IN SAUDI ARABIA: EXPERIENCE IN THE MANAGEMENT OF 164 PATIENTS WITH STAGE-I & -II DISEASE

BACKGROUND Earlier stages cervical cancer has been customarily treated with radiation therapy, surgery, or combination thereof. We present our experience in the management of stage-I and -II patients in a major cancer center in the Kingdom of Saudi Arabia. METHODS Between 1979 and 1991, 164 patients were treated and closely followed at a tertiary care medical center. RESULTS Patients accounted for 0.78 % of all cancer patient referral. More cases with earlier stages (41.3 %) were referred since 1986, compared to a lower referral (26.1%) during the earlier part of the study (p=0.027). Age ranged from 21 to 80 years with a median of 46.5 years. Clinical stages at presentation included Stage-IA (3.0%), IB (28.7%), IIA (11.6%), and IIB (56.7%). Majority (87.2%) had squamous cell carcinoma, while the rest, had adenocarcinoma (9.1%) or other malignancies (3.6%). Among the 143 patients with squamous cell cancer, eighteen had attempted radical resection, 101 were treated with radiation, and 24 had both modalities. For squamous cancer patients, fifty-one (35.7%) had disease relapse either locally (19 cases), distally (23 patients) or both combined (9 patients). The pattern of failure was unrelated to stage of disease, histological diagnosis or the mode of therapy initially administered. The cumulative five and ten years survival for squamous cancer patients was 68.3% and 57.9% respectively. Better survival was noted for patients with smaller sized tumors, free parametrium, and Stage-I disease. When all factors were considered in the regression model, only the status of parametrial involvement was found to be of significance. CONCLUSIONS Cervical cancer is relatively rare in Saudi Arabia. With the improvement in health care delivery, more patients were lately seen at earlier stages of disease. With radiation therapy, two thirds of patients survived five years. The extent of parametrial involvement was the best predictor for long term survival.

Retroperitoneal fibrosis complicating stage IB squamous cell carcinoma of the cervix

A patient with Stage IB squamous cell carcinoma of the cervix associated with benign retroperitoneal fibrosis and hydroureters is reported. It is suggested that staging laparotomy is indicated in such a case to assess whether hydroureters are related to benign fibrosis or cancer metastasis.