Bilateral papillary cystadenoma of the mesosalpinx: a rare manifestation of Von Hippel–Lindau disease

We report a rare case of a woman with bilateral papillary cystadenomata of the broad ligament with von Hippel–Lindau disease (VHL) (other manifestations: capillary hemangioblastomas of the spinal cord). Patient surveillance is important, because in the course of VHL-associated tumors malignant lesions may arise that are relevant for the prognosis.     

Intramedullary spinal cord and leptomeningeal metastases in a patient with carcinoma of the uterine cervix

BACKGROUND.: Neoplastic meningitis in patients with carcinoma of the uterine cervix is unusual in the course of their diseases. Even more unusual are intramedullary spinal metastases. CASE: We report the case of a 64-year-old woman who presented with leptomeningeal and intramedullary spinal cord metastases from a grade 2 squamous cell cancer of the uterine cervix. This is just the second case of intramedullary metastases from cervical carcinoma. CONCLUSION: Neoplastic meningitis or intramedullary metastases are extremely rare in the course of uterine cervix carcinoma. Nevertheless, when indicated by symptoms, patients should undergo MRI of the brain and/or spine and have a lumbar puncture performed, for the diagnosis of this devastating complication. Treatment is mainly palliative but may offer symptom relief.     

Preoperative serum CA-125 levels in borderline tumors of the ovary.

Preoperative serum CA-125 levels were evaluated in 38 patients who underwent primary surgery for epithelial ovarian tumors of borderline malignancy at the Brigham and Women's Hospital and Massachusetts General Hospital between 1981 and 1990. Surgical staging was Stage I in 25 (66%) patients, Stage II in 2 (5%) patients, Stage III in 10 (26%) patients, and Stage IV in 1 (3%) patient. The mean sizes of mucinous and serous ovarian tumors were 21.9 and 10.3 cm, respectively (P = 0.0002). All 13 patients (100%) with mucinous tumors had Stage I disease, while 12 (50%) of 24 patients with serous tumors were Stage I. Combining all cell types, 10 (40%) of 25 patients with Stage I disease had an elevated preoperative CA-125 level, while 2 (100%) of 2, 9 (90%) of 10, and 1 (100%) of 1 patient with Stage II, III, and IV disease, respectively, had increased preoperative levels. Among patients with serous tumors, 3 (25%) of 12 Stage I patients had an elevated preoperative CA-125 level, while 11 (92%) of 12 Stage II-IV tumors had elevated levels (P less than 0.001). These data suggest that preoperative CA-125 level correlates with stage of disease in patients with serous borderline ovarian tumors.     

Immature teratoma of the ovary

Twenty-five cases of patients with pure immature teratoma of the ovary, accrued from the Connecticut Tumor Registry from 1969 to 1984, were reviewed. Two patients had grade 1 tumors, twelve had grade 2 tumors, and eleven had grade 3 tumors. The majority of patients (23) were stage I at the time of initial surgery. Twenty-one of the twenty-three patients were treated with some form of unilateral adnexal surgery with or without adjuvant combination chemotherapy (VAC). Two of the twenty-three patients were treated with total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAH/BSO) with the addition of either VAC chemotherapy or radiation therapy. Recurrence occurred in two patients, both of whom had grade 3 tumors and were subsequently treated with surgical resection plus VAC chemotherapy. One patient, who recurred after initial therapy with unilateral salpingo-oophorectomy (USO) plus VAC chemotherapy, was successfully treated with surgical resection and further chemotherapy. Two patients were stage III at the time of initial surgery, one of whom was treated with USO plus adjuvant combination chemotherapy and radio-therapy. The other patient was treated with TAH/BSO plus VAC chemotherapy. In our series, no patient died from immature teratoma (one patient died from advanced breast carcinoma). It is reasonable to withhold chemotherapy from patients with stage I, grade 1 and 2, immature teratoma which may be treated initially with conservative surgery. The risk of recurrence in patients with grade 3 tumors warrants the addition of further chemotherapy.     

CT myelography for differential diagnosis between intramedullary and intradural-extramedullary spinal tumors in the region of the conus medullaris.

We reviewed the myelograms and computed tomographic myelograms of 12 cases of intraspinal tumor with a "cupping sign" on the myelogram in the region of the conus medullaris from 1986 to 1988. There were 5 intramedullary tumors, 4 of them having an exophytic component, and 7 intradural-extramedullary tumors. The myelograms revealed that 4 of the 5 intramedullary tumors showed expansion and the outline of the conus medullaris was irregular, whereas 1 of the tumors showed smooth compression (crescent-shaped) and displacement of the conus medullaris. Six of the 7 intradural-extramedullary tumors showed smooth compression and displacement of the conus medullaris, while 1 of the tumors had caused expansion of the conus medullaris. Complete blockage of the passage of the contrast medium was noted in 3 of the 5 intramedullary tumors, while a partial block was noted in 3 of the 7 intradural-extramedullary tumors. Two of the 7 intradural-extramedulllary tumors showed an extradural tumor component, such as a dumb-bell tumor and a enlarged intervertebral neural foramen. Tumor calcification was noted in 1 of the 7 intradural-extramedullary tumors. Dural ectasia was noted in 2 of the 7 intradural-extramedullary tumors which were later proven to be neurofibromatosis. We conclude that smooth compression (crescent-shaped) and displacement of the conus medullaris, existence of an extradural tumor component, and eroded intervertebral neural foramina favor intradural-extramedullary tumors, while expansion and a conus medullaris with an irregular outline favors intramedullary tumors.     

Preoperative CA 125 in endometrial cancer: is it useful?

OBJECTIVE: We sought to determine the clinical utility of preoperative CA 125 measurement in determining the need for lymphadenectomy in patients with endometrial carcinoma.Study Design: A prospective nonrandomized study was performed over a 2-year period. Patients referred with the diagnosis of endometrial carcinoma had CA 125 levels determined before surgical staging. Operative findings were then correlated with preoperative CA 125 values. Standard statistical calculations were used to determine sensitivity, specificity, positive predictive value, and false-positive and false-negative rates. The Student t test was used to determine differences between mean values. RESULTS: Either a CA 125 level of >20 U/mL or a grade 3 tumor or both of these correctly predicted 87% of patients requiring surgical staging. In patients with a preoperative diagnosis of stage I, grade 1 or 2 tumors, a CA 125 level of >20 U/mL correctly identified 75% (9/12) of patients requiring lymphadenectomy compared with only 50% (6/12) identified when a CA 125 level of >35 U/mL was used. Two of 16 low-risk patients with preoperative grade 1 tumors and CA 125 levels of <20 U/mL had occult extrauterine disease at surgery. CONCLUSION: Measurement of preoperative CA 125 is a clinically useful test in endometrial cancer. CA 125 levels of >35 U/mL strongly predicted extrauterine disease but lacked sensitivity in identifying patients needing staging. Either a CA 125 level of >20 U/mL or a grade 3 tumor or both of these correctly identified 75% to 87% of patients requiring lymphadenectomy. Until more data are collected, abdominal hysterectomy should be the procedure of choice for patients with grade 1 tumors and CA 125 levels of <20 U/mL.     

Surgical treatment of spinal arteriovenous malformations: vascular anatomy and surgical outcome.

BACKGROUND AND PURPOSE: Spinal arteriovenous malformations (AVMs) are rare but debilitating lesions of the central nervous system. This study evaluated the outcome in patients with spinal AVMs treated surgically, and the relationship between outcome and the vascular anatomy of the lesions. METHODS: These AVMs were classified into four types: dural AVM (type I), glomus AVM (type II), juvenile AVM (type III), and intradural direct arteriovenous fistula (type IV). Either interruption of the feeding vessels or excision of the AVMs was performed in all patients. RESULTS: Intradural AVMs manifested as subarachnoid or intramedullary hemorrhages, whereas dural AVM manifested as epidural hemorrhage in two patients, and as an episode of subarachnoid hemorrhage in one patient. The nidus in five of the six dural AVMs was below the mid-thoracic level. In six of the seven patients with intradural AVMs, the nidus was located in the cervical region. The prognosis of patients with dural AVMs was generally good, but in patients with intradural AVMs, motor recovery was worse and resection was more difficult. CONCLUSIONS: Correct diagnosis and classification of spinal AVMs are the key prerequisites for successful treatment. The surgical outcome is closely related to the vascular anatomy of the lesion. For dural AVMs, only surgical interruption of the arteriovenous shunting at the dural sleeve of the nerve is required and good surgical results are often obtained. Intradural direct arteriovenous fistula responded well to surgery, whereas combined endovascular and microsurgical techniques can minimize the chance of rebleeding in intramedullary AVMs.     

Tumor cytosol dipeptidyl peptidase III activity is increased with histological aggressiveness of ovarian primary carcinomas

OBJECTIVE: Proteolytic enzymes have been implicated in the progression of various human malignancies, including ovarian cancer. The enhanced expression of dipeptidyl peptidase III (DPP III) was found in endometrial carcinomas of various histological types and grade. The aim of this study was to assess activity of DPP III in ovarian tissue specimens and to correlate it with clinico-pathological data. METHODS: DPP III hydrolytic activity toward Arg-Arg-2-naphthylamide was determined in 108 ovarian tissue cytosol specimens of 79 patients. The data obtained for 41 ovarian primary carcinoma specimens were stratified according to clinical stage, histological grade and type, and age of the patients. RESULTS: Median DPP III activity expressed as milliunits per milligram protein was 6 in normal ovarian tissues (n = 29), 6.5 in benign ovarian tumors (n = 19), 19.5 in primary ovarian carcinomas (n = 41), 12.5 in nonepithelial primary ovarian tumors (n = 7), and 22.1 in metastatic ovarian malignancies (n = 12). A significant rise in median DPP III specific activity was observed in malignant ovarian tumors (of epithelial, nonepithelial, and metastatic origin), but not in benign ovarian tumors, compared to the activity in normal tissue. A significant difference of DPP III expression was found between the group of normal tissues and tumors of clinical stage I and II, of grade 2 and 3, of serous and mucinous histologic type. CONCLUSIONS: DPP III activity of benign ovarian tumors equaled that in normal ovarian tissue. In malignant neoplasms of the ovary it increased with growing histologic grade.     

Accurate laboratory predictions of the clinical response of patients with advanced ovarian cancer to treatment with cyclophosphamide, doxorubicin, and cisplatin

Seventy-six patients with advanced ovarian cancer treated with cyclophosphamide, doxorubicin, and cisplatin (CAP) at 3-week intervals were tested for the response of their tumors to treatment with CAP in the subrenal capsule tumor implant assay. Thirty-four of the patients' tumors were assayed prospectively before clinical treatment and 33 were assayed retrospectively, after clinical treatment with CAP. Nine of the patients' tumors were assayed both prospectively and retrospectively. All of the patients underwent a tumor debulking laparotomy. Of the patients with clinically measurable residual disease, 17 had a partial response of at least 50% regression of disease, and 11 had a progression of disease. Of the patients with known residual but nonmeasureable disease, 7 had surgically verified complete responses, 8 at least 50% regression, and 23 had progression of disease: 10 had no evidence of disease clinically but had not had surgical confirmation. Twenty-six of the tumors were adenocarcinomas not otherwise specified (2 grade I, 2 grade II, and 22 grade III), 39 were serous adenocarcinomas (7 grade I, 9 grade II, and 23 grade III), 7 were endometrioid adenocarcinoma (all grade III), 3 were mucinous adenocarcinomas (1 each of grade I, II, and III) and 1 was an adenosquamous carcinoma (grade III). Thirty-four of the patients failed the therapy. The subrenal capsule (SRC) assay predicted 21 of these failures (4 prospective and 17 retrospective). Thirty-two of the patients responded to CAP chemotherapy. The SRC assay accurately predicted the clinical regression of the tumors of 22 of the patients (15 prospective and 7 retrospective). Second-look laparotomy confirmed 7 patients with no evidence of disease, 5 patients with minimal disease, and 5 patients with a greater than 50% reduction of their disease. The SRC assay predicted the response of all these patients except 2 with partial responses to chemotherapy. Thus, while the overall positive predictive value of the SRC assay in this study is 65%, it is 100% for those patients whose tumors respond completely and for those who have minimal residual disease after CAP chemotherapy.     

Intramedullary spinal cryptococcoma: a case report.

Intramedullary spinal cryptococcosis is very rare. We describe a case of intramedullary spinal cryptococcoma at the T12 level in a 60-year-old man who presented with a 3-month history of progressive bilateral lower limb weakness and no obvious immunocompromise. Magnetic resonance (MR) imaging revealed a 1.2 cm diameter mass within the spinal cord at T12 with intermediate signal intensity on T1-weighted images, a slight degree of homogeneous low signal intensity on T2-weighted images, and intense enhancement after infusion of gadopentetate dimeglumine. These findings led to a preoperative diagnosis of intramedullary tumor. After 2 months of postoperative antifungal treatment, the patient's clinical condition had markedly improved. Cryptococcoma should be considered when an enhancing lesion of the spinal cord is found on MR imaging, even in apparently immunocompetent patients. A careful lumbar puncture for cerebrospinal fluid analysis to diagnose cryptococcosis of the central nervous system should be made promptly, as early treatment is associated with a good prognosis.     

Preoperative endovaginal ultrasound in the assessment of myometrial invasion of endometrial adenocarcinoma

OBJECTIVE: To determine, according to histological tumor grade, the reliability of preoperative endovaginal ultrasound in the detection of myometrial invasion in patients with stage I endometrial cancer. PATIENTS AND METHODS: Sixty-one patients with stage I endometrial carcinoma were evaluated with preoperative endovaginal ultrasound compared to postoperative results of pathologic examination, in a six-year retrospective study. RESULTS: Twenty-nine patients had a deep myometrial invasion (stage IC). The mean endometrial thickness was 9.5 mm in stage IA, 17.0 mm in stage IB and 20.0 mm in stage IC disease (P = 0.01). The sensitivity and the specificity of the ultrasound in the assessment of myometrial invasion in grade 1 tumors were 100% and 93.7%, respectively. They fell to 69.2% and 88.9% for high-grade tumors. The global accuracy of ultrasound was 82%. DISCUSSION AND CONCLUSIONS: The performance of preoperative ultrasound varies according to the literature. The association of morphological and morphometric criteria enables an increase in the sensitivity of the exam. In grade 1 tumors, the preoperative endovaginal ultrasound could help in identifying a group of patients at low risk of lymph node metastasis for which a pelvic lymphadenectomy would be avoidable.     

The effects of severe cystocele on urogynecologic symptoms and findings

BACKGROUND: To evaluate the effects of severe cystocele on lower urinary tract function. METHODS: Urogynecologic evaluation composed of patient questionnaire, urinary diary, pad test, Q-tip test, perineal ultrasonography and cystometry was performed on 60 patients with reducible grade III or IV cystocele before and after reduction of the prolapsed organs. The data were analyzed by Paired-t and Chi-square tests and Pearson's correlation analysis. RESULTS: One-hour pad test revealed that 17 (28.3%) of the 60 patients with reducible severe cystocele had no demonstrable urinary incontinence, while 26 (43.3%) had mild and 17 (28.3%) had moderate or severe incontinence. However, all patients had moderate or severe incontinence after reduction with vaginal packing (p<0.001). The vaginal packing had no significant effect on the maximum bladder capacity, the intravesical pressure at maximum capacity and the frequency of detrusor instability (33.3%). Whereas, urine loss after 1-hour pad test, bladder neck mobility, straining Q-tip angle and PUVA increased significantly after reduction of the cystocele (p<0.01). CONCLUSIONS: As grade III or IV cystocele may mask the presence and severity of urinary stress incontinence, preoperative urogynecological evaluation should be done after reduction of the cystocele.     

Trimetrexate in the treatment of recurrent or advanced leiomyosarcoma of the uterus: a phase II study of the Gynecologic Oncology Group.

OBJECTIVE: This study was conducted to determine the objective response of trimetrexate in patients with advanced or recurrent leiomyosarcoma of the uterus. METHODS: Eligibility was restricted to patients with measurable disease who had received no more than one prior chemotherapy regimen, who had adequate bone marrow, renal, and hepatic function, and who had recovered from previous therapy. Trimetrexate was begun at 5 mg/m2/day orally for 5 days every other week, with dose modifications specified by study design. RESULTS: Of 28 patients entered into the study, 27 were evaluable for toxicity and 23 for response. Prior therapy included radiation (7 patients) and/or chemotherapy (10 patients). Measurable disease was extrapelvic in 20 cases and confined to the pelvis in 3. The overall response rate was 4.3%; there were no complete responses and 1 partial response. Toxicities were mild to moderate with no treatment-related deaths. Hematological toxicity was most common, consisting of leukopenia (grade 1 to 2, 8 patients; grade 3 or 4, 2 patients), thrombocytopenia (grade 1 to 2, 10 patients; grade 3 or 4, 1 patient), and anemia (grade 1 to 2, 6 patients; grade 3 or 4, 4 patients. Severe (grade 3 or 4) nonhematologic toxicity was uncommon: nausea/vomiting/gastrointestinal (3 patients) and neurological (1 patient). Progression-free and overall survival, in months, was 2.2 (range: 0.9-13.4) and 7.2+ (range: 1.0-13.4+), respectively. CONCLUSION: Although toxicity is acceptable, trimetrexate at this dose and schedule is ineffective therapy for patients with recurrent leiomyosarcoma. Further development of this specific regimen for this indication is unwarranted.     

Carcinoma of the vulva involving the perianal or anal skin

From January 1, 1985, to December 31, 1987, 58 patients underwent radical vulvar surgery for primary squamous cell carcinoma of the vulva. Twenty-four (41%) of the tumors involved the perianal or anal tissues. Nineteen patients had FIGO stage III disease and five patients had stage IV disease. Nineteen of the 24 patients underwent radical excision of their tumors, without colostomy. Two of the 19 excisions included resection of the majority of the anus, and both patients were subsequently left with severe fecal incontinence. In 8 patients the resection involved partial removal of the external and sphincter. Four of these patients developed persistent postoperative fecal incontinence. In the remaining 9 patients the resection involved partial removal of the anal skin, but with the external anal sphincter intact. One of these patients had postoperative fecal incontinence which was unchanged from her preoperative state. In conclusion, carcinoma of the vulva involving perianal tissue can be resected in most cases with adequate preservation of external anal sphincter function. If the sphincter is damaged during the operation, there is a significant risk for subsequent fecal incontinence.     

Prolactin-secreting pituitary adenomas in women. II. Menstrual function, pituitary reserves, and prolactin production following microsurgical removal.

A prospective study of 46 women with prolactin-secreting pituitary adenomas and amenorrhea and/or galactorrhea was performed to determine the influence of the selective transsphenoidal removal of these tumors on pituitary and reproductive function. This procedure was effective in restoring menstrual function in 34 of 41 women and in eliminating lactation in 30 of 40 women. Tumor size and preoperative serum prolactin concentrations were the most important factors in predicting the postoperative disappearance of symptoms. Normal menstrual function returned in 33 of 34 women with tumors less than 2 cm in diameter but in only one of seven women with tumors greater than 2 cm. Similarly, galactorrhea disappeared in 29 of 34 women with tumors less than 2 cm but in only one of six women with larger tumors. Menses returned in 31 of 32 women and galactorrhea disappeared in 25 of 31 women with preoperative serum prolactin levels below 200 ng/ml; conversely, menses returned in only three of nine women and lactation ceased in one of six women with preoperative serum prolactin concentrations above 200 ng/ml. Prolactin concentrations decreased in 42 of 43 patients following the removal of pituitary adenomas and returned to normal in 30. Postoperative pituitary reserves of adrenocorticotropic hormone, growth hormone, luteinizing hormone, and follicle-stimulating hormone were normal in most patients. These data indicate that the removal of prolactin-secreting pituitary adenomas by a neurosurgeon accomplished in this surgical technique is effective in restoring menstrual function and eliminating lactation in most women, especially if the tumor is less than 2 cm in diameter and the preoperative serum prolactin concentration is less than 200 ng/ml.     

Ovarian cystectomy for serous borderline tumors: a follow-up study of 35 cases

We have investigated the frequency of persistence or recurrence of tumor in 35 patients with ovarian serous borderline tumors treated by unilateral cystectomy, bilateral cystectomy, or unilateral cystectomy with contralateral oophorectomy or salpingo-oophorectomy. Nineteen of the patients had stage Ia, ten had stage Ib, four had stage Ic, and two had stage III tumors. Tumor persisted or recurred only in the ovary that had been subjected to cystectomy in two (6%) of the 33 patients with stage I tumors, in both the ipsilateral and contralateral ovary in one patient (3%), and in the contralateral ovary only in one patient (3%). The frequency of ipsilateral persistence or recurrence of tumor per ovary subjected to cystectomy in this group of patients was 8%. Both patients with stage III tumors had persistence or recurrence of their tumors. Involvement of the resection margin of the cystectomy specimen and the removal of more than one cyst from an ovary were almost always associated with persistence or recurrence of tumor. Follow-up of the 35 patients showed that despite the occasional complication of persistence or recurrence of tumor, all were alive without evidence of disease 3-18 years after the initial operation, with an average follow-up of 7.5 and a median follow-up of 6.5 years.     

The value of transvaginal sonography in the preoperative assessment of myometrial invasion in high and low grade endometrial cancer and in comparison to frozen section in grade 1 disease

OBJECTIVE: To evaluate the diagnostic accuracy of preoperative transvaginal sonography (TVS) in the detection of deep myometrial invasion in endometrial cancer cases classified by the grade of disease, and in comparison to frozen section analysis in grade 1 cases. METHODS: In a prospective study, 91 patients with confirmed endometrial carcinoma underwent preoperative TVS for evaluation of myoinvasion. Sonographic results were categorized as superficial (less than or equal to 1/2 myometrial depth) and deep invasion (greater than 1/2 myometrial depth). TAH-BSO followed by retroperitoneal lymph node sampling were performed in all patients with grade 2-3 tumors. In patients with grade 1 disease, the surgical specimen was intraoperatively evaluated by frozen section, and lymph node sampling was carried out if deep invasion was determined. The preoperative sonographic findings and the frozen section results were compared to the final histopathology report of myoinvasion. RESULTS: In 77 of the 91 (84.6%) patients, the sonographic assessment of the depth of myoinvasion was in accord with the final histopathologic findings. TVS demonstrated a sensitivity of 87.8% and a specificity of 82.7% in detecting deep invasion in the entire study group (grade 1-3), with positive and negative predictive values (PPV, NPV) of 74.3% and 92.3%, respectively. TVS in grade 1 cases (n=47) showed a sensitivity of 77.7%, a specificity of 79%, PPV of 46.6% and NPV of 93.7%. TVS in cases with grade 2-3 tumors (n=44) showed a sensitivity of 90%, specificity of 91.6%, PPV of 90% and NPV of 91.6%. Thus, the accuracy of TVS in grade 2-3 cases was superior to that achieved in grade 1 cases (91% vs 78.7%; p=.002). The myometrial invasion was assessed by frozen section in 41 out of 47 patients with grade 1 disease and demonstrated a sensitivity of 85.7%, a specificity of 100%, PPV of 100% and NPV of 97.1%. The specificity (100%) and accuracy (97.5%) of the frozen section were found to be superior compared to that of the TVS (79% and 78.7%) in detecting deep invasion in grade 1 cases (p=.008, p=.005, respectively). No statistically significant difference was found between the sensitivity of either technique. CONCLUSIONS: TVS appeared to be a more accurate method for preoperative assessment of myoinvasion in grade 2-3 endometrial cancer patients compared to grade 1 patients. In grade 1 cases, this method achieved lower accuracy in detecting deep invasion compared to the frozen section analysis. Based on these data, the value of preoperative TVS results as the sole criterion in the decision to perform extensive surgical procedures in grade 1 endometrial cancer is questionable and warrants further evaluation.     

Epidemiologic and Surgicopathologic Findings of Papillary Serous and Clear Cell Endometrial Cancers When Compared to Endometrioid Carcinoma

PURPOSE: The aim of this study was to identify similarities and differences in epidemiologic and surgicopathologic staging results for papillary serous (PS) and clear cell (CC) endometrial cancers compared with endometrioid (EM) carcinoma of the endometrium. METHODS: Clinical and surgicopathologic data were retrospectively collected on 574 clinical stage I-II endometrial cancer patients, including 53 PS and 18 CC (based on postoperative histology), undergoing hysterectomy at Duke University Medical Center between 1967 and 1990. All staging material was available and reexamined prior to this analysis, and FIGO surgical staging was retrospectively assigned. PS and CC histologic subtypes were compared both as a common category and as discrete categories versus EM, EM grade 1 (EM1), EM grade 2 (EM2), and EM grade 3 (EM3). Fisher's exact test was used to compare proportions with unordered categories (2x2 tables), while the chi(2) test for trend was used to compare proportions in 3x2 tables with ordered categories. Differences in medians were compared with the Wilcoxon rank-sum test. RESULTS: PS tumors accounted for 8%, CC for 2%, and EM for 90% of cases. Overall, 14% of tumors were changed to a different postoperative histology including 64% of PS, 50% of CC, and 8% of EM. Postoperative histology changes were 4% for EM1 and 21% for EM3. PS, CC, and EM3 had more surgical sampling performed than for other EM. Rates for lymph node dissections were similar for EM3 (81%), PS (72%), and CC (67%) tumors, although metastases were more frequent for PS and CC compared with EM3. When PS tumors were confined to the endometrium, paraaortic metastases occurred in 13%. LVSI increased with EM grade and was highest for PS and CC. Upstaging to surgical stage III-IV occurred in 47% of PS, 39% of CC, and 12% of EM. The majority of PS and CC tumors were confined to the inner one-third of the myometrium, compared with EM tumors, where grade correlated with depth of myometrial invasion. Extrauterine metastases occurred in 55% of PS and 45% of CC tumors confined to the inner one-half, compared with 17% of EM3. CONCLUSION: Frequent changes from preoperative to postoperative histology and grade may contribute to misassignment of preoperative and intraoperative risk as determined by depth of myometrial invasion for PS and CC patients. The higher frequency of extrauterine metastases in PS and CC tumors compared with EM3, despite similar surgical sampling rates, supports a more virulent behavior. The poor correlation between depth of myometrial invasion and risk for extrauterine metastases helps to explain poorer survival in PS and CC patients, in addition to more frequent upstaging. These results support routine extended surgical staging for women with preoperative or intraoperative diagnosis of PS and CC tumors. Intraoperative assessment of tumor grade and histology may be indicated and warrants further investigation.     

The impact of complete surgical staging on adjuvant treatment decisions in endometrial cancer

OBJECTIVE: The aim of this study was to determine the impact of complete surgical staging on adjuvant treatment decisions in endometrial cancer. METHODS: Two hundred ninety-one patients with endometrial cancer treated between 1996 and 2002 were identified through patient registry. Two hundred seventy-one (93%) of these women were completely surgically staged. RESULTS: Average patient age: 64 years (23-92); average weight: 198 lb (99-350+); median follow-up: 12 months (0-77). Eighteen percent of tumors had surgical grade greater than preoperative grade. One hundred forty-nine patients had low-risk uterine factors, three with positive nodes (2%). One hundred forty-six out of 149 patients had negative nodes, received no adjuvant therapy, and four recurred (3%). Ninety-six patients had intermediate risk uterine factors, 16 with positive nodes (17%). Eighty out of 96 patients had negative nodes. Twenty-one out of 80 patients (26%) received whole pelvis radiation or chemotherapy. Three out of 21 patients (14%) had distant recurrences. Fifty out of 80 patients (63%) received no adjuvant therapy. Six out of 50 patients (12%) recurred, three distant and three distant and in the pelvis. The recurrence rate of patients with intermediate risk uterine factors that received adjuvant therapy was not statistically different than that of patients receiving no adjuvant therapy (P = 1.00, Fisher's exact test). Forty-six patients had high-risk uterine factors, 26 with positive nodes (55%). The recurrence rate for stage I disease was 5% (11/211), for stage II disease 14% (2/14), for stage III disease 21% (11/52), and for stage IV disease 50% (7/14). CONCLUSION: Complete surgical staging adds important information that influences adjuvant treatment decisions. Patients with surgical stage I and II endometrial cancer do not benefit from whole pelvis radiation therapy.     

Treatment of ovarian germ cell tumors with a 3-day bleomycin, etoposide, and cisplatin regimen: a prospective multicenter study

BACKGROUND: Ovarian germ cell tumors (OGCT) are highly curable when treated with cytoreductive surgery and platinum-based chemotherapy. We evaluated the safety and activity of a 3-day modified bleomycin, etoposide, and cisplatinum (mBEP) regimen in patients with OGCT. PATIENTS AND METHODS: Patients with FIGO stages I-IV OGCT were treated with three (stages I-III complete resection) or four cycles (incomplete resection or stage IV) of bleomycin 15 mg iv, etoposide 120 mg/m(2) iv, and cisplatin 40 mg/m(2) iv for 3 days every 3 weeks. RESULTS: Forty-eight patients (14 with dysgerminoma and 34 with non-dysgerminomatous tumors) were included in our study. Most patients had stage I disease (65%) and complete resection of their tumor (67%). Twenty percent of patients developed grade 3 or 4 neutropenia with 4 episodes of neutropenic fever. During follow-up (median: 5 years), two patients developed progressive disease including one patient who died. All patients with stage I or II disease and all patients with dysgerminoma remain free of disease. However, 20% of patients with non-dysgerminomatous tumors stage III or IV experienced progressive disease. CONCLUSION: The modified 3-day BEP regimen was safe and effective in patients with OGCT. Further improvements are needed for patients with advanced, suboptimally debulked non-dysgerminomatous tumors.