Is normal beta-hCG regression curve helpful in the diagnosis of persistent trophoblastic disease?

OBJECTIVE: The aim of this study was to evaluate the probable usefulness of normal beta-human chorionic gonadotropin (beta-hCG) regression curve in the diagnosis of persistent trophoblastic disease (PTD). METHODS: A log-value regression curve was developed from the means and 95% confidence limits of serial weekly serum beta-hCG titers of 43 patients with uneventful complete hydatidiform moles and 14 patients, who were previously confirmed as PTD. RESULTS: All 14 PTD patients (100%) had abnormal values, beyond normal range, within 4 weeks. beta-hCG was in its upper values, compared to normal regression curve at 2.29 +/- 0.19 weeks. This was earlier than plateau or rise detection at 4.21 +/- 0.33 weeks (P < 0.001). Within 3 weeks of evacuation, 13 of 14 (92.86%) PTD patients' beta-hCG values exceeded the normal range, whereas only six of 14 (42%) showed a rise or plateau. CONCLUSION: Our finding indicates that the normal beta-hCG regression curve may be useful for quicker detection of PTD than the plateau or rise of level.

EMA-EP regimen, as firstline multiple agent chemotherapy in high-risk GTT patients (stage II-IV).

Multiple agent chemotherapy in high-risk metastatic gestational trophoblastic tumor patients is a problem for any medical team. In this study, EMA-EP chemotherapy (etoposide, methotrexate, actinomycin, and cisplatinum) was evaluated as firstline chemotherapy to manage high-risk GTT metastatic patients. Seventeen high-risk metastatic patients, including 14 without and 3 with brain metastasis, who were candidates to firstline multiple agent chemotherapy between April 2000 and March 2003 in Vali-e-Asr hospital took part in a prospective study under EMA-EP regimen. EMA-EP was prescribed in two periods: EMA in two consecutive days in week 1 and EP in 1 day in the following week with a week interval between these two (each cycle was repeated every 2 weeks). In brain metastasis group, patients got high-dose medication (methotrexate) together with brain radiotherapy. Remission, toxicity, full dose tolerance, and recurrences of patients were evaluated. Median age of patients was 30 (15-49), and they received 100 courses of chemotherapy including 75 low-dose courses and 25 high-dose courses. 71% of courses were done in full dosage (83% in low dose and 36% in high dose). The most common cause for dosage reduction was leukopenia. Two patients did not complete the regimen, one due to hypersensitivity and the other due to fever and leukopenia leading to death. All others, who received complete courses, achieved remission. In the group without brain metastasis, one case of recurrence was observed. Grade 3 anemia, grade 3 and 4 leukopenia, and grade 3 and 4 thrombocytopenia were observed in 3, 12, and 3% of patients, respectively. In current study, EMA-EP regimen in patients with high-risk metastatic GTN patients (with or without brain metastasis) lead to remission in all patients who completed the treatment courses.

Multiple, disseminated cutaneous metastases of vulvar squamous cell carcinoma.

Cutaneous metastases of vulvar carcinoma are extremely rare and have been reported in six patients so far. Our patient, who is the seventh one, is a 38-year-old woman with a history of diabetes mellitus. After detecting stage III squamous cell carcinoma of the vulva, she underwent radical vulvectomy and bilateral inguinal lymphadenectomy. She received 6000 cGy external beam radiation for positive margins. Six months later, she came back with multiple advanced skin lesions. Biopsy was performed and lesions were confirmed as cutaneous metastases. For her palliation, some chemotherapy drugs were prescribed. She is on her sixth chemotherapy cycle, but these skin lesions are somewhat a preterminal event and there is no well-established treatment for this phase of disease.

Borderline ovarian tumours: clinical analysis of 38 cases.

Thirty-eight patients with ovarian tumours of low malignant potential (borderline) were diagnosed and treated in Tehran University Gynecology Oncology Department from 1991 to 2002, and have been reviewed. In this study age, clinical behavior, symptoms, surgical stage, type of tumour, surgery, adjuvant treatment, survival and recurrences were evaluated. A retrospective chart review was performed on these 38 patients who were treated for histopathologically confirmed tumours of low malignant potential between 1991-2002. The mean age was 34.4 years, range (14-83) (SD: 18.33). Post surgical FIGO staging was: Stage I=93.75%, stage III 6.25%. Histologic subtypes were: Serous 76.31% (29 patients), Mucinous 21.05% (8 patients), Mixed types 2.63% (1 patient). Mean pre-operative CA125 value was 114.90 (SD: +/- 90.30). Thirty-three percent of patients had only a simple cyst in ultrasonography. Conservative surgery was performed in 76.32% (29 patients). More radical surgery (TAH + BSO) was performed in 9 patients (23.68%). There were 6 recurrences. Three patients with recurrence and invasive implants received chemotherapy and secondary surgery was performed. Survival rate was 100% at 3 years for all stages and 89% at 5 years. One patient died of recurrent disease at 48 months after initial diagnosis. Our data suggest that LMP tumours are most frequently diagnosed in stage I. Most common histological type was serous, and 5 of the recurrences of (6 patients) were initially diagnosed at stage I, and had been treated with conservative surgery with no adjuvant therapy.

First-line chemotherapy with 5-FU and platinum for advanced and recurrent cancer of the cervix: a phase II study.

This study was designed to assess the role of first-line chemotherapy with 5-fluorouracil (5-FU) and platinum in the treatment of advanced or recurrent cervical cancer. Ten patients with advanced or recurrent cancer of the cervix with no prior chemotherapy were entered in a phase II trial from October 2000 to November 2001. Eight patients were treated with Cis-platinum (50 mg/m2 over 60 minutes on the first day) followed by 5-FU (1 g/m2 over 24 hours for 4 days) and two patients with impaired renal function were treated with carboplatin (300 mg/m2 over 15 minutes on the first day) followed by 5-FU (1 g/m2 over 24 hours for 4 days) every 3 weeks until progression of disease or prohibitive toxicity had been observed. Median age was 52 years (range 28-70 years). Ten patients received a total of 42 cycles of chemotherapy. The mean number of chemotherapy cycles was 4.2 (median 4, range 3-7). Three patients had a partial response (30%, 95% CI, 1.7-58.5%). Mean duration of response was 198 days (range 122-273 days). Four patients required red blood cell transfusions; three of them had Grade II and one of the Grade III nausea and vomiting. Two had fever and neutropenia (one developed acute renal insufficiency), and there were no treatment related mortalities. First-line chemotherapy with platinum and 5-FU for advanced and recurrent cervical cancer is promising and deserves consideration for a larger phase III trial.

Simple hysterectomy in the presence of invasive cervical cancer in Iran.

The objective of this study was to determine the reasons leading to an inappropriate simple hysterectomy in the presence of invasive cervical cancer. During 1997-2001, 62 cases of invasive cervical carcinoma that had been treated by simple hysterectomy were referred to the gynecology oncology service in Vali-e-Asr hospital, Tehran, Iran. Five had microinvasive carcinoma. The remaining 57 women had either adenocarcinomas or squamous cell carcinoma (SCC). Medical records were reviewed retrospectively to determine the reasons for inappropriate hysterectomy. Reasons for inappropriate hysterectomy were as follow: lack of preoperative Pap smear (P/S) (29%), deliberate hysterectomy for biopsy-proven cancer (25.8%), negative P/S (6.5%), inadequate evaluation of abnormal P/S (6.5%), failure to perform an indicated conization (3.2%), and emergent operation because of uterine perforation (1.6%). Reasons for inappropriate hysterectomy in the remainder of patients (27.4%) were not found because of lack of sufficient information. Although 45.2% of these patients had complained for vaginal bleeding, only four of them had preoperative endocervical and endometrial sampling. Despite the increasing emphasis on performing cervical cancer screening before hysterectomy, only 18 (29%) referral patients had preoperative P/S. We conclude that by close adherence to the cervical cancer screening guidelines and appropriate evaluation of the presenting symptoms, we may avoid inappropriate management of cervical carcinomas with simple hysterectomy. Many cases of simple hysterectomy in the presence of biopsy-proven squamous cell carcinoma of the cervix necessitates some reconsideration of gynecology oncology postgraduate courses for general gynecologists.