Nodal metastasis in endometrial cancer.

PURPOSE: Besides hysterectomy and bilateral salpingo-oophorectomy, the goal of surgery in early endometrial cancer is to identify extrauterine disease. The purpose of this study was to evaluate disease characteristics and survival of patients found to have nodal metastasis at staging for endometrial cancer. METHODS: All patients presenting to our practice from January 1993 to July 2009 with a new diagnosis of early endometrial cancer underwent pelvic and paraaortic lymph node sampling at the time of surgery as permitted by the body mass index. Patient and disease characteristics of patients with nodal metastasis were abstracted by retrospective chart review. Factors contributing to disease-free and overall corrected survival were evaluated. RESULTS: Forty-three patients with an early endometrial cancer were found to have pelvic and/or paraaortic nodal metastasis. Thirty-three percent of patients with nodal metastasis had papillary serous or clear cell cancers. Such tumors were often superficially invasive, yet were more likely to demonstrate lymphovascular space involvement as compared to endometrioid cancers. Furthermore, in a global model of disease-free and overall corrected survival, only tumor histology (endometrioid vs non-endometrioid) was a significant prognostic factor. Excluding clear cell and papillary serous tumors, only tumor grade was a significant prognostic factor in disease-free survival and overall corrected survival in patients with endometrioid adenocarcinomas and nodal involvement. Following adjuvant treatment after surgery, the recurrences were nearly evenly divided between pelvic, paraaortic nodal and distant sites. Only four of 33 (12%) patients treated with adjuvant pelvic radiation experienced a failure in the irradiated field. Furthermore, none of the patients experiencing a paraaortic nodal recurrence received adjuvant radiation to this site. CONCLUSIONS: The data suggest a benefit to the use of adjuvant radiation for local control of disease. Furthermore, the use of paclitaxel and carboplatinum chemotherapy also appears a promising adjunct in patients with endometrioid histologies and nodal spread. Papillary serous and clear cell cancers contributed disproportionately to the incidence of nodal metastasis and an adverse prognosis following further adjuvant therapy of patients with nodal disease. Despite taxol/carboplatinum chemotherapy, over half of the patients with non-endometrioid cancers recurred, as opposed to one of 19 endometrioid cancers so treated. The ideal form of adjuvant treatment for such patients remains problematic.

Vulvar Paget disease: fluorescein-aided visualization of margins.

Two women with extramammary Paget disease of the vulva were given fluorescein intravenously in order to visualize disease margins with the use of an ultraviolet light. As a diagnostic modality, the technique was found to have a positive predictive value of 97.4% and a negative predictive value of 99.9%. The accuracy of the fluorescein technique was compared with gross visualization using a histologic mapping technique. A total of 2424 fields were mapped and the predictive accuracy of each test was determined. A chi 2 test demonstrated fluorescein visualization to be a significantly better predictor of a disease state. Fluorescein visualization is suggested as an adjunct to surgical management of patients with primary vulvar Paget disease.

Successful treatment of cervical pregnancy with oral etoposide.

Cervical ectopic pregnancy is an uncommon entity associated with significant morbidity and devastating effects on future fertility. A woman with a cervical gestation with quantitative serum beta-hCG levels higher than 46,000 mIU/mL and fetal cardiac activity on ultrasound was treated successfully with one course of oral etoposide, a fetocidal agent, which avoided operative intervention and preserved the patient's fertility.

Recurrent Paget disease of the vulva in a split-thickness graft.

Recurrent Paget disease developed in a vulvar split-thickness skin graft, the second reported case of recurrence of this type and the first without an underlying dermal adnexal adenocarcinoma.

Pelvic fibromatosis: case report and review of literature.

The case report of a patient with pelvic fibromatosis is described. Excision of the tumor without sacrificing organs or major vessels was performed. Although not malignant, this tumor can be life-threatening due to its locally invasive properties. A variety of therapeutic options are discussed.