Contemporary surgical management of borderline ovarian tumors: a survey of the Society of Gynecologic Oncologists.

OBJECTIVE: The objective of this study was to review the current practice patterns regarding the surgical management of borderline ovarian tumors. METHODS: A one-page survey was mailed to the members of the Society of Gynecologic Oncologists (SGO), using the directory of the Society. The survey addressed the demographics of the respondent and the recommended staging procedure for presumed early-stage disease. RESULTS: Of the 660 surveys mailed, 274 (42%) were returned. Ninety-seven percent (267/274) of respondents advocate surgical staging. Of this group, 96% (257/267) perform peritoneal washings, 97% (259/267) sample the omentum, and 92% (245/267) submit random peritoneal biopsies. Eighty-eight percent (235/267) perform lymph node sampling: paraaortic biopsies by 89% (210/235) and pelvic biopsies by 97% (228/235). Of this latter group, 91% sample the external iliac chain, 82% submit hypogastric nodal tissue, and 70% remove obturator lymph nodes. CONCLUSION: Diversity exists in the surgical management of borderline ovarian tumors among members of the SGO who responded to this survey. Efforts to ensure a consistent approach to the management of borderline ovarian tumors are warranted.

Diagnosis and treatment of disseminated struma ovarii with malignant transformation.

Struma ovarii are specialized teratomas consisting of thyroid tissue. They may demonstrate all pathologic features seen in the thyroid gland. Malignant transformation of thyroid tissue in struma ovarii is uncommon and is rarely recurrent or metastatic. We report the diagnosis and treatment of a recurrent struma ovarii with malignant transformation, and intraperitoneal, retroperitoneal, and hepatic metastases.

Malignant myxoid sarcoma of the Bartholin gland in pregnancy.

A case of myxoid sarcoma of the Bartholin gland occurring during pregnancy is reported. This neoplasm possessed pathologic features consistent with a high-grade malignancy. The patient underwent a wide reexcision of the clinically negative operative site 8 weeks post partum, and no residual evidence of sarcoma was identified. In spite of this, a local recurrence occurred 10 months later. This was reexcised, and localized electron beam teletherapy was administered.

Primary adenoid cystic carcinoma of Skene's glands.

A unique case of a 50-year-old woman is reported who presented with a suburethral mass in the anterior vaginal wall. The resected tumor was an adenoid cystic carcinoma arising from Skene's glands. Tumor was not involving Bartholin's glands. In addition to the typical glands and areas with cysts containing periodic acid-Schiff positive intraluminal material, less well-differentiated areas with neoplastic cells growing in a trabecular or solid pattern were also seen. Prominent perineural invasion was noted throughout the tumor. Immunostaining revealed positive reactions for cytokeratins, carcinoembryonic antigen, and focally for S-100 protein. Ultrastructural studies showed epithelial cells with well-formed basal lamina and prominent microvilli. This case illustrates an uncommon site, the Skene's glands for adenoid cystic carcinoma in the female genitourinary tract.

Comparative study of laparoscopy vs. laparotomy for adnexal surgery: efficacy, safety, and cyst rupture.

Operative laparoscopy is becoming routine in gynecologic surgery. This study was designed to compare the safety and efficacy of laparoscopy and laparotomy for ovarian cystectomy and adnexectomy. The medical records of 32 patients who underwent operative laparoscopy for adnexal masses (group L) were reviewed and compared with those of 32 patients who underwent surgical laparotomy (group S) for similar indications. All patients sustained either an ovarian cystectomy or adnexectomy. The group were matched for age, weight, and history of previous laparotomy. Median operating time for group L was 90 min and for group S was 85 min. Blood loss was significantly less in group L (33.4 +/- 22 mL) than in group S (84.6 +/- 22.2 mL), p < 0.0001. There were two intraoperative complications in group L and one in group S. Significantly less patients in group L had postoperative fevers (16%) as compared with those in group S (69%), p < 0.0001. There was a higher incidence of cyst rupture when cystectomy was performed in patients from group L (7 of 21) as compared with patients from group S (2 of 17). No such difference in cyst rupture was noted when an adnexectomy was affected in group L (1 of 11) and group S (1 of 15). Patients in group L remained in the hospital a shorter time period, 1.5 +/- 0.8 days, than patients in group S, 4.7 +/- 0.9 days, p < 0.0001. Patients in group L required a shorter postoperative recovery time before resuming normal activities, 9.1 +/- 6.6 days, than patients in group L, 27.5 +/- 9.2 days, p < 0.0001. Similarly, patients in group L required less time to become pain free, 10.1 +/- 7.4 days, than patients in group L, 17.7 +/- 6.1 days, p < 0.0005. This study demonstrates a statistically significant decrease in postoperative morbidity and faster recovery in patients undergoing laparoscopy for adnexal surgery as compared with patients undergoing laparotomy for the same procedure. When cystectomy is performed via the laparoscope, there is a higher incidence of cyst rupture than with laparotomy.

Para-aortic node sampling in small (3-cm or less) stage IB invasive cervical cancer.

Only 2 of 125 patients with FIGO stage IB invasive squamous or adenocarcinoma of the cervix 3 cm or less in diameter who underwent exploration for radical hysterectomy, bilateral pelvic lymphadenectomy, and para-aortic node sampling had metastases to the para-aortic nodes. No patient had gross para-aortic nodal involvement, and both patients with microscopic para-aortic nodal metastases had grossly positive pelvic nodal involvement. Para-aortic node sampling in patients with small stage IB cervical cancers undergoing radical hysterectomy may be restricted to patients with suspicious pelvic or para-aortic nodes.

5-year survival of patients with periaortic nodal metastases in clinical stage IB and IIA cervical carcinoma.

From 1969 to 1981 thirty-six patients with stage IB and IIA cervical carcinoma were identified at pretherapy surgical staging laparotomy with histologically documented metastatic disease to the periaortic lymph nodes. All patients underwent a periaortic node dissection and all patients completed a course of extended-field radiotherapy in a postoperative setting. No major radio-therapeutic complications were encountered. The 5-year actuarial survival rate was 50%, with a median survival time of 29 months. The median time to recurrence was 10 months, while the median duration of survival following a recurrence was 7 months. Seventy-five percent of all recurrences occurred at distant sites. These data demonstrate that survival may be favorably influenced by employing extended-field radiotherapy in those patients with early-clinical-stage cervical cancer and periaortic nodal metastases. The subsequent development of distant metastases after such a treatment regimen emphasizes the need for adjuvant cytotoxic chemotherapy to enhance overall survival.

Imaging strategies for MRI of the pelvis.

Appropriate patient triage of pelvic diseases depends upon a problem-solving approach as outlined in this article. Whether MRI is chosen as an adjunct to US or CT or as the primary modality, as in the staging of malignancy, imaging strategies for pelvic MRI can be tailored to the organ of interest and to the clinical question being asked.

Surgical staging of gynecologic malignancies.

The role of surgical staging in gynecologic malignancies has not been precisely defined at this time despite the conventional employment of this modality in the initial staging of ovarian neoplasms. Major discrepancies have been documented between clinical and surgical estimates of disease extent in cervical, endometrial, and vulvar carcinomas. We recently reviewed our experience with patients who were found to have positive periaortic nodes after surgical exploration for clinical Stage IB and Stage IIA cervical cancer. Postoperative extended field radiotherapy was employed with minimum complications and the 5-year actuarial survival rate was 50% with a median survival time of 29 months. In order to justify the utilization of surgical staging for gynecologic neoplasms, it is necessary to demonstrate a survival advantage in patients where the precise extent of disease has been established and subsequent therapy tailored accordingly. In addition, it must be shown that surgical staging does not increase complications or decrease the efficacy of subsequent therapeutic interventions.

MRI in staging of endometrial and cervical carcinoma.

MRI of 54 patients with endometrial and cervical carcinoma was performed on a 0.6-T superconducting magnet. In 18 of 24 cases of surgically proved endometrial carcinoma, MRI accurately showed the depth of myometrial invasion. MRI was superior to CT scan for defining the primary site and extent of the tumor in 14 of 24 cases. Of 25 patients with cervical carcinoma studied, MRI was superior to CT scan in 15 of 19 cases with CT correlation for localizing the primary site. MRI showed parametrial extension and invasion of surrounding structures but is probably less reliable than CT scan for detection of adenopathy because of false positive findings from volume averaging with bowel.

The value of MRI in evaluating perirectal and pelvic disease.

MRI of the perirectal region is facilitated by the superb soft tissue contrast, multiplanar imaging capability, lack of respiratory motion artifact and absence of clip artifact which can hamper visualization by CT scan. MRI provides distinct advantages over CT scanning without the need for ionizing radiation or the injection of intravenous contrast material. This study reviews the findings in 18 consecutive patients with a variety of perirectal pathologies including rectal carcinoma (3), gynecologic neoplasm (8), sacral lesions (2), pelvic arteriovenous malformations (2), inflammatory bowel disease (2), and a pelvic kidney (1). In the perirectal region, MR was useful to show normal tissue planes, benign processes which can mimic neoplasm, intrapelvic extension of malignancy and adenopathy.

Flow cytometry of peritoneal washings in gynecologic neoplasia.

A prospective, double blind study was initiated to compare flow cytometry to cytopathology in detecting malignant cells within peritoneal washings. Deoxyribonucleic acid (DNA) histograms were generated using 4',6-diamidino-2-phenylindole (DAPI) as a DNA fluorochrome. Evaluation of these data revealed a correlation of 84.5% with the cytologic findings. Two specimens demonstrated euploidy in the presence of cytologically malignant cells (false negative), 28 of 128 specimens (21.8%) manifested aneuploidy with negative cytologic findings (false positive). Further evaluation of this latter subgroup revealed 22 of the 28 to possess unequivocal histologic evidence of malignancy, thus yielding an actual false positive rate of 4.7%. This preliminary study demonstrates that flow cytometry is a highly sensitive, accurate, and analytic method for the detection of malignant cells within peritoneal washings and that it may augment the cytologic examination. However, additional comparative studies are necessary to conclusively demonstrate its apparent diagnostic potential.

Malignant melanoma of the vulva.

During the years 1969 to 1982, 16 patients with primary malignant melanoma of the vulva were entered into the Tumor Registry at the University of Miami Jackson Memorial Medical Center. The mean age was 55, with a range of 18 to 89 years. Treatment was primarily by radial vulvectomy with bilateral groin and pelvic node dissection. Survival was correlated to FIGO staging, Clark and Breslow classifications, and lymph node involvement. Survival correlated best to tumor thickness and Clark levels. Patients with Clark level 2 or less and less than 1.5 mm depth of penetration had the best prognosis. Lymph node involvement was present in 25% of the patients, and there were no survivors in this group. There were no instances of positive pelvic nodes when the groin nodes were negative, and routine pelvic lymphadenectomy is not recommended.

Treatment of advanced or recurrent endometrial adenocarcinoma with cyclophosphamide, doxorubicin, cis-Platinum, and megestrol acetate.

A prospective clinical trial using combination chemotherapy consisting of cyclophosphamide, doxorubicin, cis-Platinum and megestrol acetate (CAP-M) was initiated to study its effect on advanced or recurrent endometrial adenocarcinoma. Fifteen patients were clinically evaluable. Nine patients (60%) demonstrated an overall objective clinical response resulting in either complete regression of disease (33%) or a reduction in tumor size. For all responders the mean progression free interval was eight months, with a range of five to 11 months. Similarly, a mean survival time of 12 months with a range of five to 21 months was observed. An additional four patients showed no progressive disease for a mean of seven months duration. Reversible cis-Platinum-induced nephrotoxicity occurred in two patients. This is the first reported series of endometrial cancer patients using nonhormonal cytotoxic agents, including cis-Platinum, in conjunction with a progestin. This preliminary experience is encouraging and appears worthy of further clinical evaluation.

Serum protein binding of salicylate during pregnancy and the puerperium.

A detailed study of salicylate binding to human serum albumin was undertaken because of the widespread use of the drug, its deleterious effect on fetal development (in the laboratory animal) and its well-documented adverse effects on neonatal well-being. Serum was obtained from 82 patients during each trimester of pregnancy, labor, 4 days and 6 weeks post partum. Equilibrium dialysis at 4 degrees C was carried out utilizing therapeutic levels of C-labeled sodium salicylate. Scatchard plots were employed to translate the data into association constants (k') which characterized the binding affinity between salicylate and albumin. At the primary binding site, the mean k' values were: controls (nonpregnant females) 40, first trimester 32, second trimester 28, third trimester 26, labor 15.5, 4 days post partum 18.4, and 6 weeks post partum 37.6 X 10 M. These results demonstrate a decrease in the binding affinity between salicylate and serum albumin as pregnancy proceeds to the puerperium, at which time the binding affinity increases to near control values at 6 weeks post partum. The transplacental concentration of free (unbound) salicylate would be readily available for transplacental transport to exert an effect upon fetal receptors. The changes found may be attributable to competitive or allosteric binding of endogenous compounds such as hormones, characteristic of the normal physiology of pregnancy.