Referral patterns for gynaecological radiotherapy in Victoria.

A retrospective chart review was undertaken on all patients in Victoria who were referred for radiotherapy for a gynaecological cancer from February 1997 to January, 1998. Three hundred and ten patients were identified which represents less than one-third of all gynaecological cancers diagnosed in Victoria each year. Ninety-two of the 310 patients (30%) referred for radiotherapy were managed without the prior involvement of a certified gynaecological oncologist. The 310 patients included 95 patients with cervical cancer, 33 patients with ovarian cancer and 142 patients with endometrial cancer. The initial management strategies employed for patients with the major gynaecological cancers varied depending on the source of referral. This difference was most marked in endometrial cancer due mainly to differing indications for full surgical staging and subsequent referral for radiotherapy both between types of specialists and also between gynaecological oncology units. The development of evidence based guidelines in the major gynaecological cancers should lead to a more uniform approach to the care of women with gynaecological malignancies.

Panniculectomy: a useful technique for the obese patient undergoing gynecological surgery.

OBJECTIVES: To establish the safety and efficacy of panniculectomy at the time of surgery for benign and malignant gynecological disease. METHODS: Retrospective review of the course of 57 patients undergoing radical gynecological surgery and panniculectomy between January 1992 and January 1997 at the Mercy Hospital for Women, Melbourne. Data were collected regarding indication for treatment, operative details, and complications of surgery. RESULTS: Of 57 patients in the study, 32 had a primary gynecological malignancy, 11 had benign gynecological disease, 3 had cervical dysplasia, 5 had endometrial hyperplasia, and the remaining 6 had incisional hernia repair. The mean age of patients was 55 years with a mean weight of 101 kg (range 70-145 kg). The mean operative time was 2 h 24 min, and blood transfusion was undertaken in 23 (41%) patients. Four (7.1%) individuals had a minor wound infection and 3 (5.4%) a moderate wound infection. One patient experienced a nonfatal pulmonary embolus and 2 patients experienced a deep vein thrombosis. There were no postoperative deaths. Long term, 6 patients developed an incisional hernia. CONCLUSIONS: Panniculectomy is a useful technique in obese patients. It improves surgical access facilitating radical surgery and is cosmetically pleasing to the patient. It has acceptable morbidity when compared to conventional midline vertical or transverse incisions in comparable populations.

Primary vaginal cancer after hysterectomy.

OBJECTIVES: We sought to examine the patients who developed vaginal cancer after prior hysterectomy and to determine whether any of these cancers could have been prevented. METHODS: The records of patients treated with vaginal cancer over a 15-year period in the Department of Gynecologic Oncology at the Mercy Hospital for Women were reviewed. Those patients who had developed a vaginal cancer after hysterectomy between 1980 and 1994 were identified. RESULTS: A total of 1,511 primary gynecological cancers were treated between 1980 and 1994, and 23 (1.5%) were primary vaginal cancers. Of these 23 patients, 13 had had a prior hysterectomy (57%). Four of the 13 patients (31%) were asymptomatic and presented after routine vault smears, and 9 were symptomatic and were diagnosed after further investigation. All 13 patients had squamous cell cancers. Two patients had had a history of cervical intraepithelial neoplasia (CIN) grade 3 reported on cervical smear but not been accounted for, both cone biopsy and hysterectomy having found no histological abnormality. CONCLUSIONS: Primary vaginal cancer is uncommon. After hysterectomy, vaginal vault cytology should continue to be performed if high-risk factors, such as history of lower genital tract neoplasia, are present. The two patients with unaccounted-for CIN3 reported on Papanicolaou smear may have had undiagnosed vaginal intraepithelial neoplasia grade 3 (not CIN3) resulting in vaginal cancers 10 and 15 years later. Therefore, when colposcopy is being performed to investigate an abnormal Pap smear, the entire lower genital tract always should be examined.

Paclitaxel (Taxol) as salvage therapy for relapsed ovarian cancer.

Thirty-two patients with epithelial ovarian cancer received paclitaxel 175 mg/m2, by 3-hour infusion, in this prospective phase 2 study. All patients had relapsed or progressed after initial cisplatin/cyclophosphamide therapy. Thirteen patients received paclitaxel as second line therapy, 14 as third line therapy and 5 as fourth line therapy. One patient was excluded from efficacy analysis, due to a severe anaphylactic reaction to the first cycle of paclitaxel therapy. Of the 31 evaluable patients, complete remission was observed in 3 patients (9.7%) and partial remission in 11 patients (35.5%), with a total response rate of 45.2%. The median survival from diagnosis for the 31 evaluable patients was 32.5 months and the median survival following therapy with paclitaxel was 12.2 months (range 4-27 months). The 3 patients who achieved a complete response remain alive, at greater than 20 months, since commencing paclitaxel. Twelve patients (38.7%) who achieved a partial response, or had stable disease, had a median survival, after paclitaxel treatment, of greater than 18 months. This study confirms the activity of paclitaxel in relapsed ovarian cancer and demonstrates a prolonged survival benefit in greater than one third of this group of patients.

An open multicentre study of tropisetron for cisplatin-induced nausea and vomiting.

OBJECTIVES: (i) To assess the efficacy and tolerability of tropisetron when used for acute and delayed cisplatin-induced emesis. (ii) To investigate whether dexamethasone added to tropisetron improves the control of emesis for patients who do not achieve a complete response to tropisetron alone. (iii) To assess sex of the patient and alcohol intake as prognostic factors for nausea and vomiting. DESIGN: A prospective open label phase II trial over one or two cycles of chemotherapy. Data collection was based on observed response and patients' self-reporting. SETTING: Twenty Australian tertiary care hospitals in 1994. PATIENTS: 102 male and female patients from 18 to 75 years with histologically confirmed malignancy receiving their first chemotherapy containing > or = 50 mg/m2 cisplatin. INTERVENTION: In Cycle 1 tropisetron 5 mg was given intravenously before chemotherapy on Day 1, then 5 mg orally before breakfast on Days 2 to 6. In Cycle 2, dexamethasone 20 mg intravenously on Day 1, then 8 mg orally on Days 2 to 6 could be added to tropisetron if a complete antiemetic response had not been achieved in Cycle 1. MAIN OUTCOME MEASURES: Number of vomiting episodes and severity of nausea for 6 days after chemotherapy; severity of side effects; patient satisfaction with chemotherapy treatment; oestradiol levels in women; and past alcohol consumption in men and women. RESULTS: (i) The complete response rate (CR) for acute emesis in Cycle 1 was 64% (95% confidence interval [CI], 54%-72%), with 84% (95% CI, 76%-90%) having < or = 2 vomits. The CR for delayed emesis was 24% (95% CI, 17%-32%). The CR for acute nausea was 56% (95% CI, 47%-66%), with 97% (95% CI, 91%-99%) having < or = 2 nausea episodes. The CR for delayed nausea was 21% (95% CI, 14%-30%). Seventy-one patients received Cycle 2. The main side effects were headache (20 patients) and constipation (16 patients). The control of acute emesis was rated as "good" or "very good" by 68% of investigators; 85% rated the tolerability of treatment as "good" or "very good". Treatment was rated as "very satisfactory" or "satisfactory" by 52% of patients. (ii) The CR for acute emesis with dexamethasone added was 78% (95% CI, 64%-88%). (iii) Women with lower oestradiol levels had better control of emesis, although this difference was not statistically significant. Chronic alcohol intake and binge drinking were strongly associated with a complete acute antiemetic response. CONCLUSIONS: Tropisetron was effective for acute cisplatin-induced emesis; adding dexamethasone enhanced this response. Both single and combined therapy had less effect on delayed emesis. The impact of alcohol on control of emesis is a chronic rather than acute phenomenon which requires prospective testing.

Cytology in the follow-up of cervical cancer.

OBJECTIVE: To determine the value of cytology in the follow-up of cervical cancer. STUDY DESIGN: The study group consisted of 230 patients with invasive cervical carcinoma who were followed for one to seven years. Forty-four patients developed recurrences or metastases. During this period, cytologic investigations involved 795 exfoliative smears from the cervix or vaginal vault, 10 fine needle aspirates and 5 fluids. RESULTS: Thirty-three patients had positive or inconclusive cervical or vault smears that were histologically proven to be recurrences, and the other 11 patients had clinically obvious recurrences that were not smeared. Cytology first alerted the clinicians to recurrence in eight patients. Of 25 cervical or vault smears reported as malignant, 24 (96%) were histologically confirmed, and 1 showed radiation change on biopsy. In all 22 cases of smears reported as inconclusive, a biopsy followed, and in 9 (41%) of these, recurrence was demonstrated histologically. Inability to distinguish radiation change from recurrent malignancy was the chief cause of inconclusive smears. Five fluids and seven fine needle aspirates were diagnosed as malignant, saving patients an invasive diagnostic procedure. CONCLUSION: Cytology is a useful, cost-effective, noninvasive and accurate investigation in the follow-up of cervical cancer.

Invasive cervical cancer in pregnancy.

Cervical cancer is the commonest malignancy which complicates pregnancy, but the management remains controversial. We reviewed our patients in an attempt to identify the best management options which resulted in long-term survival for the mother and a live baby. The total number of pregnancies managed between January, 1981 and March, 1995 was obtained from the hospital records, and patients with invasive cervical cancer diagnosed during pregnancy or within 12 months of delivery were identified. The case records were reviewed. Between January, 1981 and March, 1995 there were 22 cases of cervical cancer diagnosed either during pregnancy or within 12 months postpartum. This gave an incidence of cervical cancer associated with pregnancy of 1 in 3,817 pregnancies or 0.26 per 1,000 pregnancies. Eleven patients had microinvasive disease. Nine were treated by cone biopsy and 2 by radical hysterectomy. Nine patients had Stage 1B and 1 had Stage 2A disease and all were treated with radical hysterectomy. One patient had Stage 3B disease and was treated with radiotherapy and chemotherapy followed by simple hysterectomy. Fourteen patients delivered vaginally. Twenty of the 22 patients were delivered of live babies which survived. The patients have been followed from 1 month to 13 years with only 1 recurrence, and all 22 remain alive. We conclude that all pregnant women should have a Pap smear performed antenatally. Cone biopsy can be safely performed in pregnancy and may be adequate treatment for microinvasive squamous cell carcinomas. Treatment, including the timing of delivery, must be individualized, with the patient playing an important decision-making role.

Grapelike leiomyoma of the uterus.

A 24-year-old nulliparous woman underwent laparotomy for a large pelvic mass. Grapelike tumor extending from the uterus into the broad ligaments and peritoneal cavity was found. A diagnosis of sarcoma appeared likely, but radical surgery was avoided when frozen sections indicated a histologically benign smooth muscle tumor.

The use of cervicography in the follow-up of cervical intraepithelial neoplasia treated by CO2 laser.

After treatment for cervical intraepithelial neoplasia (CIN) the follow-up of patients would be simplified if colposcopy could be safely omitted. A study of 50 patients was performed to determine the feasibility of such an approach. Cervical cytology, cervicography and colposcopy, with or without biopsy, was performed in each patient. From the results the following criteria for colposcopy were adopted: (a) patients thought to have CIN on cytology or cervicography, (b) inadequate cervicography picture (vagina covering cervix or poor quality photography), (c) high-risk factors present (immunosuppression, after cone biopsy, postmenopausal). In this study the number of colposcopies would have been reduced from 50 to 11 if these criteria were adopted. Cervical cytology combined with cervicography is a reasonable alternative to colposcopy and we feel this is a technique worth pursuing for the follow-up of patients treated for CIN.

Extrauterine malignant mixed müllerian tumor of primary peritoneal origin.

The case of an extrauterine heterologous malignant mixed müllerian tumor (MMMT) of primary peritoneal origin occurring in a 63 yr old woman is presented. The tumor was a 19 cm, soft, friable mass arising from the serosa of the sigmoid colon and spreading to adjacent pelvic peritoneum. The uterus, tubes and ovaries were uninvolved. It was composed of sarcomatous areas showing cartilaginous and rhabdomyoblastic differentiation and sharply demarcated carcinomatous areas showing endometrioid and serous differentiation. This is the thirteenth reported case of an extragenital MMMT. It demonstrates the pluripotentiality of female pelvic peritoneum to differentiate into tumors resembling those of the genital tract.

Parathyroid hormone-related protein and human papillomavirus in gynecological tumors.

The presence of parathyroid hormone-related protein (PTHrP) and human papillomavirus (HPV) in a series of gynecological tumors from 131 unselected patients was examined. PTHrP was localized immunohistochemically using a highly specific rabbit polyclonal anti-serum against PTHrP(1-16). The results confirmed that gynecological malignancies, although rarely associated with humoral hypercalcemia of malignancy (HHM), stained for PTHrP in a majority of the squamous-cell carcinomas (SCC) at all sites, but only in a minority of adenocarcinomas, and then in areas of squamous metaplasia. This included a series of endometrial tumors. Detection of HPV types was achieved using a polymerase-chain-reaction (PCR) detection system enabling the detection of HPV types 6, 11, 16, 18, 31, 33 and 45. PTHrP production was not directly related to HPV infection, but correlated with the type of tumor.

The treatment of gynaecological malignancy in a general public hospital.

OBJECTIVE: To assess the adequacy of treatment of gynaecological cancer in a public hospital and to determine the influence of referral patterns on patient outcome. DESIGN: A retrospective analysis of clinical histories. SETTING: A tertiary-level general public hospital. PATIENTS: 89 patients admitted between 1 January 1979 and 31 December 1987 for primary treatment of a gynaecological malignancy. MAIN OUTCOME MEASURES: The primary study parameter was patient survival. During data analysis, the study parameters were altered to include the adequacy of initial surgery and survival time in relation to the involvement of the Gynaecology Unit. RESULTS: Initial presenting symptoms had a major influence on the referral patterns of patients with a gynaecological malignancy. All patients who presented with abnormal vaginal bleeding were managed by the Gynaecology Unit. Patients with ovarian cancer who presented with non-specific abdominal symptoms and ascites were often managed by other units. There was a statistically significant difference in the adequacy of initial surgery depending on whether the patient was managed by the Gynaecology or the Surgical Unit (P < 0.05). The median survival time of patients managed by the Gynaecology Unit was 20 months; this was considerably longer than the figure of 14 months for other units (P < 0.05). CONCLUSIONS: Patients with ovarian cancer who are managed by a specialised gynaecology unit are more likely to have adequate initial surgery and a longer median survival time. Female patients presenting with non-specific abdominal symptoms, ascites and other signs of intra-abdominal malignancy should be reviewed by a gynaecology unit before initial surgery.

Maximum effort in the management of ovarian cancer, including pelvic and para-aortic lymphadenectomy.

Patients treated for ovarian cancer at the Mercy Hospital for Women, Melbourne over a 5 1/2 year period were studied with an emphasis on the need for lymphadenectomy. There were 80 patients identified with ovarian cancer. Forty patients underwent pelvic and/or para-aortic lymphadenectomy and 25 (62.5%) were found to have lymph node metastases, in 7 of the 40 women the lymphadenectomy resulting in upstaging of the disease. FIGO has adopted a surgicopathological approach to the staging of ovarian cancer and this requires lymphadenectomy to be performed. The importance of accurate staging in clinically early ovarian cancer and maximum surgical effort in advanced disease is discussed with particular regard to the place of lymphadenectomy.

Intraepithelial and invasive neoplasia of the vulva in association with human papillomavirus infection.

Colposcopic examination of 335 women with cytologically detected human papillomavirus (HPV) revealed involvement of the cervix in 316 patients (94%), vagina in 276 (82%) and vulva in 148 (44%). A symptom complex of pruritus and superficial dyspareunia was found in 98 of the 148 patients with vulvar infection (66%). Histologic examination revealed HPV-associated vulvar intraepithelial neoplasia (VIN) in 11 of 148 biopsies (7.4%). Follow-up of the patients with HPV infection with or without VIN showed a spontaneous regression rate of 56% but also demonstrated progression to VIN 3 in two patients and to invasive carcinoma of the vulva in one.

Continuous epidural morphine analgesia after radical operations upon the pelvis.

Sixty-seven patients with gynecologic malignant disease received continuous epidural morphine as a postoperative analgesic after radical surgical treatment. An average of 0.005 milligrams per kilogram of body weight per hour of morphine was given, with a mean total postoperative dose of 33.42 milligrams. Pain control was excellent in 88 per cent of the patients and no major complications occurred with this technique. Side effects included: nausea (33 per cent); vomiting (9 per cent), and generalized pruritus (25 per cent). Epidural morphine provided a constant pain-free state with unimpaired consciousness, normal motor function and hemodynamic stability. This technique allows the early institution of aggressive physiotherapy with an actively participating patient and provides an ideal postoperative analgesia for the high risk patient to be cared for in an intensive nursing area.

Multifocal invasive carcinoma of the vulva in a 25-year-old woman with Bowenoid papulosis.

This case report documents malignant progression associated with wart virus infection of the vulva in a 25-year-old female. The initial condition of Bowenoid papulosis and carcinoma in situ of the vulva was diagnosed on colposcopic biopsies performed to investigate chronic pruritus and superficial dyspareunia. This condition failed to resolve with local ablative therapy and progressed over a period of 8 months to multifocal invasive carcinoma of the vulva requiring radical surgery. Deoxyribonucleic acid hybridization studies on the operative specimen revealed the presence of human papilloma virus type 16. The role of human papilloma virus in the aetiology of Bowenoid papulosis and neoplasia of the vulva is discussed.

Human papilloma virus infection and associated intraepithelial neoplasia of the cervix, vagina and vulva.

A prospective colposcopic and histological study was performed on 333 patients with cytologically detected human papilloma virus infection (HPV) without cytological evidence of associated intraepithelial neoplasia. The colposcopic changes seen in the cervix, vagina and vulva were documented and target biopsies were taken from abnormal areas in these 3 sites. Colposcopic and histological evidence of HPV infection was found in the cervix of 314 patients (94%), vagina in 274 patients (82%) and vulva in 146 patients (44%). Histologically proven cervical intraepithelial neoplasia was found in 94 of 333 patients biopsied (28%), vaginal intraepithelial neoplasia in 3 of 333 patients biopsied (0.9%) and vulval intraepithelial neoplasia in 9 of 146 patients biopsied (6.2%). This study identified the colposcopic changes of HPV infection to be widespread throughout the lower female genital tract. The diagnosis of intraepithelial neoplasia undetected by cytology in 28% of patients with HPV infection indicates that such patients require colposcopy and target biopsy according to the colposcopic findings.

Primary malignant fibrous histiocytoma of the uterus--ultrastructural and immunocytochemical studies of two cases.

The clinical and pathological features, including ultrastructural and immunocytochemical findings, of 2 cases of primary malignant fibrous histiocytoma of the uterus are reported. One patient had pulmonary metastases at the time of hysterectomy: she developed pelvic recurrence and died 3 mth after operation. The other patient was well and apparently free of disease 6 mth after hysterectomy. Histologically both tumours resembled pleomorphic leiomyosarcoma, and the diagnosis of a malignant fibrous histiocytoma was confirmed only after electron microscopic and immunocytochemical studies. Hormone receptor assay for estrogen and progesterone was positive in both tumours. Anti-estrogen treatment was started in one case but was ineffective.