Phase I-II study of combined 5-fluorouracil and cisplatin chemotherapy and altered fractionation radiotherapy for advanced squamous cell carcinoma of the cervix.

Forty patients with advanced carcinoma of the cervix were prospectively treated by an intermodality approach using chemotherapy combination concomitant with split-course hyperfractionated radiation therapy (RT). Cisplatin (CDDP) (60 mg/m2) was administered before radiotherapy initiation followed by 5-fluorouracil (5-FU) (750 mg/m2) for 5 days during the first week of irradiation. The same schedule was repeated in the last week of the RT, with 5-FU administration (1,000 mg/m2) for only 3 days. RT consisted of 5,020 cGy to the pelvis, followed by two intracavitary applications for a total of 5,000-5,500 mg/h radium equivalent when possible: 140 cGy/fraction was administered in the morning and evening, with a 6-h interval. The remainder of the external beam radiation was delivered at a standard daily fractionation of 180 cGy/fraction to a total dose of 5,020 cGy. This regimen of RT with concomitant chemotherapy had minimal toxicity and did not cause significant prolongation of the treatment program. However, a high rate of late complications was noted in patients who had extended-field RT due to paraaortic lymph node involvement. Thirty-two patients had complete response (CR) (80%). 24 (75%) of whom have no evidence disease (NED), with a median follow-up of 24 months. Our study suggests that this regimen of combined chemotherapy and RT in this group of patients with poor prognosis is effective and well tolerated, with acceptable acute toxicity and late morbidity.

Leuprolide acetate for treating refractory or persistent ovarian granulosa cell tumor.

OBJECTIVE: To evaluate leuprolide acetate for treating refractory or persistent ovarian granulosa cell tumor (GCT). STUDY DESIGN: We treated six patients who had recurrent or persistent ovarian GCT with monthly intramuscular injections of a depot formulation of leuprolide acetate, 7.5 mg. Four patients had received prior cisplatin-based chemotherapy. Initially these patients' tumors had responded to the cisplatin, but then the disease had progressed in all cases. One of these four patients also had received prior therapy with tamoxifen that had resulted in three months of stable disease. Two patients had received no prior chemotherapy. RESULTS: Responses could be evaluated in five of the six patients; in the sixth patient, only survival was evaluable. Among the five evaluable patients, two achieved partial responses lasting 3 and 11 months, with disease progression-free intervals of 4 and 12 months. The other three patients (60%; 95% confidence interval [CI], 20-95%), including two whose disease had progressed on chemotherapy, had stable disease with disease progression-free intervals of 3+, 3+ and 13+ months. The objective response rate was 40% (two of five patients; 95% CI, 10-90%). Cessation of disease progression was noted in all five of the evaluable patients (100%; 95% CI, 40-100%). The sixth patient, whose disease could not be evaluated, was treated with leuprolide acetate for 24 months and at this writing had no clinical evidence of disease. The therapy was convenient to administer, and no major side effects were noted. Leuprolide acetate thus appears to have activity in patients with refractory GCT, and it may prolong the disease progression-free interval. Further trials of this relatively nontoxic and convenient therapy are warranted.

Aggressive fibromatosis of the female pelvis. A case report and review of the literature.

Aggressive fibromatoses (desmoid tumors) are rare tumors of fibroblastic origin that may arise in any musculoaponeurotic structure with a propensity of infiltrate adjacent tissues, but not to metastasize. Tumors of musculoaponeurotic origin are seldom encountered by the gynecologist. A case of pelvic fibromatosis is reported together with a discussion of theories of etiology and management options.

Aggressive angiomyxoma of the pelvis and perineum. A case report.

BACKGROUND: Aggressive angiomyxoma of the female perineum and pelvis is a slowly growing neoplasm occurring almost exclusively in women of reproductive age. The tumor is characterized by its locally infiltrative behavior. The high recurrence rate has been attributed to incomplete surgical excision. CASE: A case of a huge, recurrent, aggressive angiomyxoma of the perineum and pelvis was treated. CONCLUSION: Correct preoperative diagnosis and assessment of simultaneous perineal and pelvic involvement indicate a combined abdominoperineal surgical approach to achieve wide, tumor-free margins.

Solitary breast metastasis as first manifestation of ovarian carcinoid tumor.

Carcinoid tumor metastatic to the breast is very uncommon. The rarity of this finding may be the reason for its common misinterpretation as primary breast carcinoma. A patient with primary ovarian carcinoid that presented initially with a solitary breast mass is reported. A review of the literature discloses only 12 reported cases of carcinoid tumor metastatic to the breast, with none of the primaries found to be the ovary.

Second primary cancer arising from the neovulva following reconstruction with myocutaneous flaps.

Myocutaneous flaps have been used for vulvar reconstruction following radical vulvectomy. For over 15 years the most common complications related to these flaps are sloughing of the skin and donor site wound infection. A new malignancy arising from the skin of the neovulva is an unusual occurrence. Two cases are presented. The skin of the neovulva may be exposed to the same neoplastic carcinogens that caused the initial lesion. In both patients, the polymerase chain reaction method failed to detect the presence of human papillomavirus DNA in either the initial lesion or the recurrent cancer.

Fallopian tube cancer metastatic to the breast.

The breast is an infrequent site of metastatic disease from a primary genital tract malignancy. A case of fallopian tube carcinoma metastasizing to the breast is presented. A solitary metastasis must be distinguished from the primary breast cancer as the treatment and prognosis are quite different. The pathologic diagnosis of metastatic carcinoma to the breast may be difficult if the tumor is poorly differentiated type.

Malacoplakia of the vagina presenting as a pelvic mass.

Malacoplakia is an unusual type of chronic inflammation that rarely involves the female genital tract. A case of malacoplakia involving the vaginal cuff of a patient previously treated by radical hysterectomy for cervical carcinoma is presented.

Vulvar malignancy.

Treatment of invasive vulvar malignancy has become more individualized during the past decade. In the past, radical vulvectomy with bilateral inguinofemoral lymphadenectomy was the standard therapy for invasive squamous cell carcinoma and melanoma of the vulva. This is no longer always the case. The treatment of stage I and stage II invasive squamous cell carcinoma of the vulva has become more individualized. Less radical surgery appears to produce the same results as ultraradical surgery. Wide local excision of early lesions associated with ipsilateral lymph node dissection appears to be adequate therapy in many cases. Likewise, treatment of early melanoma (0.75 mm in thickness) can be managed by wide local excision with or without groin dissection of the ipsilateral side. This more conservative approach has resulted in significantly fewer postoperative complications and has improved the self-image of many women undergoing treatment for vulvar malignancy.

Human dura mater allografts in repair of pelvic floor and abdominal wall defects.

Freeze-dried human dura mater has been used as an allograft for reconstructive gynecologic surgery since 1980. So far, 33 grafts have been placed. This versatile and immunologically inert material has been used to reconstruct the pelvic floor after exenterative procedures, replace rectus fascia in the repair of wound dehiscence and ventral or parastomal hernias, and cover the femoral vessels after nodal dissection. In seven patients, dura mater was grafted into infected sites without subsequent rejection. Biopsy of an allograft one year after implantation confirmed the natural tendency of the body to convert the dura mater to a viable and neovascularized tissue. This reconstructive material is a safe and versatile allograft for gynecologic oncologists.

Antibiotic prevention of infections complicating radical abdominal hysterectomy.

In this randomized, double-blind study, the effectiveness of a single-agent prophylactic antibiotic in reducing infections after radical abdominal hysterectomy with pelvic and para-aortic lymphadenectomy was compared with a placebo. A total of 12 doses of cefoxitin (2g) or placebo were given to 70 patients, starting the evening before surgery. Because of tumor spread beyond the cervix, radical hysterectomy was not performed in 17 patients who were, therefore, excluded from the study. Analysis of 53 patients who completed the study revealed that 15% of cefoxitin patients had surgical site-related infections compared with 52% of placebo patients (P = .005). Significant differences between the groups were also observed in nonsurgical site-related infections (23 versus 48%), overall morbidity (58 versus 89%), and the need for additional antibiotic therapy (38 versus 67%). Socioeconomic status was a significant risk factor with 57% of staff patients demonstrating increased site-related infections as compared with 17% of private patients (P = .002). No clinically significant side effects were observed. The authors recommend the use of antibiotic prophylaxis in patients undergoing radical abdominal hysterectomy for gynecologic malignancies.

Pelvic exenteration: a 15-year experience in a general metropolitan hospital.

Between June, 1966, and June, 1981, 92 pelvic exenterations were performed by gynecologic oncologists at Jackson Memorial Hospital/University of Miami Medical Center. The decrease in postoperative morbidity and mortality and the improved 5-year survival rate probably were related to improvement in hospital facilities and more refined surgical techniques. Urinary and gastrointestinal complications occurred with equal frequency during the period of study and were more common in patients who had received previous radiation therapy. On the basis of our experience, recommendations to decrease gastrointestinal and urinary complications further are presented.

Paget's disease of the skin. A unifying concept of histogenesis.

Utilizing the peroxidase antiperoxidase technique we explored the presence and the distribution of carcinoembryonic antigen (CEA) in seven cases of mammary and sixteen of extramammary Paget's disease of skin. In every case positive immunostaining was observed in all the Paget's cells and the underlying tumor (where one was present), whereas intervening keratinocytes and melanocytes did not stain. CEA was also present in the cells and secretions of normal eccrine and apocrine glands. Our observations confirm that Paget's cells are of glandular origin.

Treatment of advanced cervical cancer by combination of bleomycin and mitomycin-C.

A combination of bleomycin and mitomycin-C, reported as extraordinarily effective in a previous clinical trial, was used to treat 20 patients with advanced cervical cancer. Seven partial remissions (35%) and one complete remission (5%) were observed. Six of the partial remissions were of short duration (less than four months); the only patient with complete remission was still alive without evidence of disease ten months after initiation of chemotherapy. Nonresponders had a mean survival time of 6.6 months and responders 8.0 months. The treatment results confirm some efficacy of the drug regimen, although in our hands it did not live up to the high expectations raised by others.