Total laparoscopic hysterectomy versus total abdominal hysterectomy for obese women with endometrial cancer.

Obesity is common in endometrial cancer and surgery for these patients is challenging. We compared total laparoscopic hysterectomy (TLH) with total abdominal hysterectomy (TAH) with respect to feasibility (operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy) and safety (perioperative morbidity and mortality) in a retrospective analysis of 78 morbidly obese patients with endometrial cancer. Analysis is based on the intention to treat. The intention to treat was TLH in 47 patients and it could be successfully completed in 42 patients (89.4%). The mean weight for all patients was 118.7 kg, with patients in the TLH group weighing more and having higher ASA scores. Mean operating time and estimated blood loss were similar in both groups. Mean postoperative hospital stay was 4.4 (+/-3.9) days in the TLH group and 7.9 (+/-3.0) days in the TAH group (P < 0.0001). Wound infections occurred in 15 of 31 patients (48.4%) in the TAH group and in 1 of 47 patients (2.1%) in the TLH group. All other morbidity, as well as patterns of recurrence and survival were similar in both groups. These data justify a prospective randomized trial comparing TLH with TAH for the treatment of endometrial cancer.

The Western Australian experience of the use of en bloc resection of ovarian cancer with concomitant rectosigmoid colectomy.

OBJECTIVES: The aim of this study was to assess the technique of en bloc resection of ovarian cancer with concomitant rectosigmoid colectomy, in relation to perioperative complication rates, and its impact on survival following the procedure. METHODS: A retrospective review was performed of the case notes of 129 consecutive procedures performed between 1989 and 2000 in a regional cancer center. RESULTS. Overall, 48.8% of patients suffered a major or minor complication. Complications relating to bowel anastomosis occurred in 2.4%. Perioperative mortality was 3.1%. Median survival for the group as a whole was 30.6 months. Patients who were optimally debulked had a significantly longer median survival time. CONCLUSION: En bloc resection of ovarian cancer with concomitant rectosigmoid colectomy allows a high rate of optimal debulking with acceptable morbidity, mortality, and survival.

Using a vaginal tube to exteriorize lymph nodes during a laparoscopic pelvic lymphadenectomy.

Laparoscopic pelvic lymphadenectomy for gynecological malignancy involves mobilizing and exteriorizing the lymph nodes. We removed the nodes by passing a 4- to 5-cm-diameter tube through the vagina to the abdomen following the hysterectomy. The nodes were passed through the tube rather than pulled through the abdominal ports. The tube is easy to insert and is a valuable conduit for exteriorizing tissue during laparoscopic pelvic surgery for gynecological cancer.

Using a vaginal tube to separate the uterus from the vagina during laparoscopic hysterectomy.

Hysterectomy performed totally by laparoscopy has few advocates because separating the cervix from the vagina is difficult. This technical difficulty can be overcome by placing a wide-bore plastic tube in the vagina to expose the cervico-vaginal junction and stretch the vaginal fornices. The stretched vagina falls away from the cervix as diathermy cuts over the tube rim. The tube guides the incision, and the plastic protects any adjacent structures. The most convenient external diameter is between 4-5 cm. Made from smooth, electrically-inert plastic, the tube's opposite distal end has a valve that maintains the pneumoperitoneum. We have used it in 73 cases, and the only associated complication has been one vault pelvic hematoma.

Uterine papillary serous carcinoma in a 32-year-old with Turner's syndrome.

The association of Turner's syndrome and endometrial carcinoma has been previously established but has never been described in conjunction with a uterine papillary serous carcinoma (UPSC). This histological variant is usually found in considerably older women and has no clear relationship to the prior use of estrogen replacement therapy. Despite presenting with stage IV disease, treated by surgery and medroxyprogesterone only, this patient has had an 8-year disease-free remission, suggesting that radical debulking of an endocrine-responsive tumor may be of considerable benefit to some women with this unfavorable histological subtype of endometrial carcinoma.

Mixed serous-endometrioid carcinoma of the uterus: pathologic and cytopathologic analysis of a high-risk endometrial carcinoma.

A review of the pathology and cytopathology of 295 endometrial adenocarcinomas treated surgically at King Edward Memorial Hospital for Women, with full 5-year follow-up, revealed 16 cases of pure serous carcinoma (USC), 10 cases of mixed serous and endometrioid carcinoma with a predominant serous component (mixed USC-EAC) and six cases of mixed serous and endometrioid carcinoma with a predominant endometrioid component (mixed EAC-USC). The mixed carcinomas may be characterized microscopically by classical serous features side by side with classical endometrioid features, or additionally by features intermediate between the two. Many of these features are reproduced in preoperative cervicovaginal smears. USC and mixed USC-EAC were found to be indistinguishable clinically and prognostically, with an identical corrected 5-year survival of 40%, although numbers are small. Mixed EAC-USC (which contained 10-25% serous differentiation in this series), however, were similar in many respects to a control population of 95 EAC of Grade 2 and 3. The corrected 5-year survival in these two groups was 67% and 79%, respectively, which is not statistically significant in this small series. This study suggests that the behavior of a mixed tumor containing 50% or more serous differentiation is similar to that of pure serous carcinoma, and that the behavior of a mixed tumor containing less than 25% serous differentiation is similar to that of the other component. Given the poor correlation between pathologic findings in curettage and subsequent hysterectomy specimens, however, identification of any significant serous element in curettage material may prove vital in optimizing surgical and adjuvant therapy.

Can laparoscopic assisted hysterectomy safely replace abdominal hysterectomy?

OBJECTIVE: To evaluate the feasibility, safety and advantages of laparoscopic hysterectomy. DESIGN: Retrospective review. SETTING: St. John of God Hospital, Perth, Australia. SUBJECTS: Fifty-four women scheduled to undergo laparoscopic hysterectomy for a variety of benign gynaecological conditions. MAIN OUTCOME MEASURES: Failure to complete the operation laparoscopically, time taken in theatre, incidence of febrile morbidity, incidence of major complications, duration of post-operative stay in hospital, interval from operation to full activity and return to work. RESULTS: Laparoscopic hysterectomy was attempted in 54 women. A total of 53 operations were completed laparoscopically with one conversion to laparotomy because of haemorrhage. Major complications occurred in two women, both of whom required further surgery. There were four cases of febrile morbidity. The average duration of post-operative stay was four days (range 2-9), with return to normal activity in two and a half weeks and to work in three weeks. CONCLUSIONS: Laparoscopic hysterectomy can be successfully achieved in most women selected for the procedure. Serious complications are inherent to some of the techniques used, but these can be overcome by modifications. Proper training and supervision in laparoscopic surgery is essential during the learning phase of the technique. There are considerable advantages to eligible women in terms of a rapid return to normal activities and work.

En bloc resection of epithelial ovarian tumors with concomitant rectosigmoid colectomy: the KEMH experience.

Between the years 1984 and 1988, 43 patients with bulky advanced stage epithelial ovarian carcinoma underwent en bloc pelvic resection with excision of the rectosigmoid colon as part of their primary cytoreductive surgery. Optimal cytoreduction was accomplished in over 70% of cases, and all women had complete debulking of their pelvic tumor. Primary anastomosis of the bowel was feasible in all cases and only two covering colostomies were performed. There were no postoperative leaks or fistulas. The postoperative morbidity was reflected by a mean postoperative hospital stay of 16 days. Our results suggest that this technique facilitates optimal cytoreduction of bulky pelvic tumor with an acceptably low morbidity in woman with advanced ovarian carcinoma.

Unusual gynaecological presentations of donovanosis as pseudo-elephantiasis and carcinoma of the cervix.

We report 2 unusual gynaecological manifestations of Donovanosis in young tribal aborigines. The first patient presented for medical attention after haemorrhaging from a large pedunculated lesion arising from the left labium minus and majus. This lesion was subsequently confirmed as pseudo-elephantiasis resulting from long-standing Donovanosis of the vulva. The second patient, with initial findings consistent with a diagnosis of advanced cervical malignancy, was referred to the oncology service of a tertiary referral centre. Because of her age and race a differential diagnosis of Donovanosis was considered and subsequently confirmed on special staining (Warthin-Starry) of biopsy specimens. No evidence of malignancy was found in these specimens.

Detection of pS2 messenger RNA in gynecological cancers.

Estrogen-inducible pS2 mRNA was previously detected in human cancer cell lines the growth of which was sensitive to estrogen. In the present study, the expression of the pS2 gene was analyzed in 111 gynecological carcinomas. The pS2 message was detected in greatest abundance in 6 primary carcinomas of the ovary (6 of 29), 4 of these being mucinous cystadenocarcinomas. A secondary carcinoma of the ovary, and another of the omentum (1 of 4), also contained detectable levels of pS2 mRNA. Weak pS2 mRNA signals were occasionally observed in endometrial (2 of 55) and cervical carcinomas (2 of 33) as well. There was a poor correlation between estrogen receptor and pS2 mRNA in ovarian carcinomas.

Surgery of intraepithelial neoplasia, CIN, VAIN, and VIN.

The various surgical treatments of CIN, VAIN, and VIN have been discussed. The necessity for careful pretreatment, histological diagnosis and colposcopic mapping of the various conditions has been stressed. The relative risks of malignant progression of the various conditions have been discussed along with the various modes and methods of surgical therapy. The facts emerging are that traditional surgical therapy is giving ground to more modern techniques of ablation, particularly that of carbon dioxide laser photoevaporation therapy. Particularly in treatment of CIN and VIN, laser therapy has begun to show many advantages. Traditional surgical techniques for treatment of intraepithelial neoplasia of the lower genital tract in the female have, in response, become more conservative in their application with an emphasis on preservation and reconstruction. However, in some cases confirmation of early results by long-term follow-up will be necessary. The general tendency of close surveillance and conservative treatment befits the management of non-invasive genital tract intraepithelial neoplasia.

A chromosome study of three ovarian tumors.

The cytogenetic results of three different types of malignant ovarian tumors are reported. Their chromosomes were studied indirectly by using either peritoneal washings or ascitic fluids. Detected in the peritoneal washings from a treated case of serous cystadenocarcinoma with papillary involvement, stage III, was a clone of pseudodiploid cells. They were found after 12 months of chemotherapy. No supporting evidence of malignancy was found cytologically. Relatively simple karyotypes were obtained from metaphases found in the ascitic fluid of a patient surgically treated for an immature teratoma, stage II, grade 3. Consistent abnormalities found were trisomy 2, del(3)(p14), and der(5)t(5;8)(q33;q11). Of prime interest in a case of dysgerminoma, stage IV, was the finding of the isochromosome i(12p), a recognized nonrandom abnormality of malignant testicular tumors [1-5].

The influence of estrogen and progesterone receptors on survival in patients with carcinoma of the uterine cervix.

The prognostic value of estrogen receptors (ER) and progesterone receptors (PR) was studied in 246 women with primary carcinoma of the uterine cervix. In addition to the receptor status information on tumor stage, histological type, age at operation, and menopausal status was recorded and analyzed. If the patient died the cause of death was ascertained. The median survival time for the 97 patients who died was 15 months and the survivors were followed for an average of 34 months. The survival curve was compared with an age, sex, and year of death matched West-Australian population. The survival curves for patients with ER+ or ER- and PR+ or PR- tumors were virtually indistinguishable. Overall survival in patients with cervical carcinoma is not influenced by the receptor status or the receptor concentration of the carcinoma.

Primary cytogenetic abnormality detected in an endometrial adenocarcinoma.

Cytogenetic findings obtained from an endometrial adenocarcinoma stage 1A are reported. The primary stem line was pseudodiploid with an abnormal chromosome #8. Three side lines were noted, which collectively involved chromosomes X, #8, #12, and two members of group D. A small percentage of cells was either pseudotetraploid or near-tetraploid. Double minutes were noted in one of the latter cells. Interest in the case is centered on the finding of what appeared to be the primary chromosomal change.

Occult, high-risk endometrial cancer.

In a series of 173 consecutive patients with endometrial cancer treated by a fixed protocol 62 tumors (36%) appear "estrogen independent," i.e. there is no history of estrogen ingestion and no recognized risk factors such as obesity or diabetes mellitus. A high proportion of these tumors are of advanced stage and grade. Prognosis is poorer and mortality higher than for "estrogen-dependent" tumors. Twenty-two tumors were truly occult (no spontaneous vaginal bleeding). Factors which identify this high-risk group are described and the reasons for delay in diagnosis discussed. Spread by intraperitoneal dissemination is considered a major factor in the poorer prognosis. Cytology of peritoneal washings is a useful diagnostic and prognostic aid. An estrogen provocation test is suggested as a means of earlier recognition which could reduce mortality in this group.

The effect of estrogen receptor status on survival in patients with endometrial cancer.

This study demonstrates a significantly increased survival time for women with estrogen receptor-positive adenocarcinoma of the endometrium when compared with that of those with estrogen receptor-negative tumors (p less than 0.05). This prognostic factor provides information which is additional to, and independent of, that provided by the histologic grade and myometrial penetration of the tumor.