The efficacy of adjuvant platinum-based chemotherapy in Stage I uterine papillary serous carcinoma (UPSC).

OBJECTIVE: To determine the efficacy of adjuvant platinum-based chemotherapy in Stage I uterine papillary serous carcinoma (UPSC). METHODS: A retrospective multi-institutional investigation was performed to identify surgically staged patients with Stage I UPSC who were (1) treated after surgery with 3-6 courses of platinum-based chemotherapy without radiation from 1990-2003, and (2) followed for a minimum of 12 months, or until recurrence. RESULTS: Six patients (IA-2, IB-3, IC-1) were treated with carboplatin (AUC 6) or cisplatin (50 mg/m2) alone. One patient recurred to the vagina, was treated with chemo-radiation, and is alive and well at 122 months. One patient recurred to the lung, liver, and brain, and died of disease at 24 months. The remaining 4 patients are alive with no evidence of disease 15-124 months (mean 62 months) after treatment. Two patients (IB-1, IC-1) were treated with cisplatin (50 mg/m2) and cyclophosphamide (1000 mg/m2), and both are alive and well with no evidence of disease 75 and 168 months after treatment. Twenty-one patients (IA-5, IB-13, IC-3) were treated with a combination of carboplatin (AUC 6) and paclitaxel (135 mg/m2-175 mg/m2). One patient recurred to the vagina after 3 cycles of carboplatin/paclitaxel, and was treated with chemo-radiation. She is now without evidence of disease 10 months after treatment. At present, all 21 patients with Stage I UPSC treated following surgical staging with carboplatin/paclitaxel chemotherapy are alive and well with no evidence of disease 10-138 months (mean 41 months) after treatment. CONCLUSION: Combination carboplatin/paclitaxel chemotherapy following surgery is effective in the treatment of Stage I UPSC.

Stage I ovarian carcinoma: specialty-related differences in survival and management.

BACKGROUND: In patients with FIGO (International Federation of Gynecology and Obstetrics) stage I ovarian carcinoma given care with or without subspecialists, we compared completeness of initial staging and disease-free survival. METHODS: Two groups of patients with stage I ovarian carcinoma were compared. Patients were managed by either gynecologic oncologists or community-based physicians. The two groups were compared for similarities in demographic, tumor, and substage characteristics and survival differences. RESULTS: Fifty-four patients with stage I ovarian cancer were included. The two groups were comparable in age, gravidity, parity, grade, and substage. Substaging was determined to be adequate in 100% of the gynecologic oncologist group and 28% of the community-based group. Postoperative chemotherapy was given to 79% and 36% of the two groups, respectively. Six-year survival was 90% in the gynecologic oncologist group and 68% in the community-based group. CONCLUSIONS: Of these two groups of patients with stage I ovarian cancer, the group managed without gynecologic oncology involvement had significantly less adequate staging, decreased administration of chemotherapy, and lower survival rates.

The accuracy of frozen section by tumor weight for ovarian epithelial neoplasms.

This study evaluated the effect ovarian weight has on the accuracy of frozen sections in serous and mucinous ovarian tumors. The study group included 294 patients who had an initial frozen section (189 serous and 105 mucinous tumors) at surgery. The pathology reports were separated into subgroups (benign, borderline, or malignant). Tumors were broken down into three weight categories: < or = 450 g, > 450 to < or = 1360 g, and > 1360 g. In each weight category, accuracy, sensitivity, specificity, and positive and negative predicative values were calculated on frozen sections. The mean weight of the ovarian tumors was 1042 g. As the weight increased in serous tumors, the sensitivity fell from 96.2 to 93.8 to 75%, respectively, in each weight category. The same trend was noted with mucinous tumors as sensitivity fell from 91.7 to 87.5 to 66.7%, respectively. With an increase in the size of ovarian tumors, a decrease in the sensitivity of frozen section was observed. With tumors greater than 1360 g, sensitivity was only 69%. Twenty-three percent of ovarian tumors revealing borderline diagnosis at frozen section were malignant on the final pathology report, with the greatest misclassification in > 1360-g mucinous tumors (50%). For patients with large ovarian tumors, consideration should be given to performing staging at the time of the initial laparotomy.

The prognostic implication of ascites in advanced-stage ovarian cancer.

Ovarian carcinoma accounts for greater than 50% of the gynecologic cancer deaths in the United States each year. One of the central reasons for this dismal outcome is that many patients present with advanced disease. In this series, a retrospective review of 130 patients with stage III and IV invasive epithelial ovarian carcinoma was performed to determine the prognostic significance of ascites. Patients were divided into two study groups based upon the presence or absence of ascites. Survival for the entire study group was 15%, but differed markedly when separated for the presence of ascites. In these patients, ascites was associated with a statistically decreased 5-year survival of 5% versus 45% without ascites (P = 0.0001). Individuals were found to be similar in each group when examined for age, height, weight, cell type, grade, and surgical and chemotherapeutic treatment modalities. More patients proportionately with stage IIIC disease had ascites than those without ascites (P = 0.0015). More of the individuals without ascites underwent second-look laparotomies and achieved a negative result than those with ascites (P = 0.04; P = 0.0038). We conclude that ascites in the presence of stage III and IV disease produces an almost uniformly fatal outcome.

Small bowel herniation after laparoscopically assisted vaginal hysterectomy.

Laparoscopically assisted vaginal hysterectomies have been done with increasing frequency in the United States. To date, minimal complications have been noted with this procedure. The authors review a series of 90 individuals and note a three percent small bowel obstruction rate. This complication is more common in this group of patients than in patients having a standard abdominal hysterectomy. Since this operation has been commonly performed, it is often possible to convert an abdominal hysterectomy to a vaginal approach, this increase in complications is exceedingly high. The authors recommend closure of lateral abdominal wall port sites under direct laparoscopic visualization to prevent this serious complication.

The efficacy of a sonographic morphology index in identifying ovarian cancer: a multi-institutional investigation.

Transvaginal sonography (TVS) has been shown to be the most effective means to screen for ovarian cancer. TVS is associated with a high sensitivity and specificity. However, the positive predictive value associated with TVS in the diagnosis of malignancy is low. A morphologic scoring index for use with TVS has been used at the University of Kentucky since 1991. The current study was performed to more fully evaluate the efficacy and interobserver variation in ultrasonographic morphology index scores attributed to ovarian tumors. Ultrasound records of 213 patients from five participating centers were reviewed by three independent observers. Morphology index scores were assigned to each tumor in a blinded fashion. The morphology index scores were then compared with the final histopathologic findings. One hundred sixty-nine patients had benign tumors and 44 patients had ovarian malignancies. The mean morphology index scores were significantly higher in malignant ovarian tumors (MI 7.3 +/- 1.9) than in benign ovarian tumors (MI 3.3 +/- 1.8). Statistical evaluation of the morphology index scores revealed a sensitivity of 89% and a positive predictive value of 46%. Interobserver variation was lowest in assessing ovarian volume and higher in the evaluation of wall structure and septal structure. A multilogistic regression model was used to evaluate the predictive power of each component of the morphology index. The use of a morphology index is an effective and cost-efficient method of increasing the positive predictive value of TVS screening for ovarian cancer. Use of this index in large numbers of patients will generate data which should help refine appropriate structural scoring categories and reduce interobserver variation.

Recurrent ovarian sex cord tumor with annular tubules: tumor marker and chemotherapy experience.

Recurrent sex cord tumor with annular tubules is an unusual ovarian cancer. The authors report a patient with recurrent disease that was ultimately followed with multiple tumor markers. During this period the patient was treated only with chemotherapy. Her regimen consisted of a combination of etoposide, bleomycin, and cisplatin. The tumor markers that were followed were CA-125, CEA, inhibin, and Müllerian-inhibiting substance (MIS). There was no elevation of the CA-125 or CEA, but inhibin and MIS proved to be effective markers. Serum inhibin and MIS correlated perfectly with her documented disease status and was brought into the normal range when the patient was disease-free. This disease-free status was proven by surgical reexploration. This report is the first documented complete response in this rare malignancy treated by chemotherapy alone with distant metastatic spread. It also gives strong linkage of inhibin and MIS as good markers in this particularly rare malignancy.

Metastatic gastric cancer presenting as a pelvic mass.

Traditionally, the gynecologist is the primary physician involved in the assessment of an adnexal mass. History, physical examination, and radiologic evaluation often fail to reveal extrapelvic etiologies for an adnexal mass, especially in the premenopausal woman. Recently three premenopausal women with a pelvic mass referred to the gynecologic oncology service at the University of Kentucky were each found to have gastric carcinoma metastatic to the ovary. This paper discusses the clinical presentation of these women and the indications for the evaluation of the upper gastrointestinal tract in a patient with an adnexal mass.

Immunohistochemical staining for CA-125 in fallopian tube carcinomas.

From 1981-1991, 15 patients with primary fallopian tube carcinomas were treated at the University of Kentucky Medical Center. Immunohistochemical staining for CA-125 was performed on tumor specimens from all cases. Thirteen tumors (87%) stained positively for CA-125. Antigen staining was most intense in the apical portions of carcinoma cells. Serum CA-125 levels were measured in 5 patients and were elevated in 4 (80%). There was a positive correlation between tumor and serum antigen expression in these cases. Serum CA-125 levels accurately reflected disease status in the patients studied. These data suggest that CA-125 is a useful marker in patients with fallopian tube carcinoma. Immunohistochemical localization of CA-125 in tumor tissue should predict which patients will benefit most from serial antigen determinations.

Transition from benign to malignant epithelium in mucinous and serous ovarian cystadenocarcinoma.

The slides of all patients with ovarian cystadenocarcinoma treated at the University of Kentucky Medical Center from 1966-1990 were reviewed. Fifty-four serous tumors and 42 mucinous neoplasms were identified for further study. Benign epithelium adjacent to an area of borderline or malignant epithelium was observed in 74 tumors (79%) and a site of epithelial transition was noted in 38 cases (40%). The presence of associated benign epithelium was more common in borderline or well-differentiated lesions and in patients with early-stage disease. These findings are consistent with epidemiologic and molecular genetic data and suggest that certain benign serous or mucinous ovarian tumors have the potential for malignant transformation. Removal of these tumors, particularly in postmenopausal women, should result in a subsequent reduction in the frequency of ovarian cancer.

Endometrioid carcinoma of the ovary and endometriosis: the association in postmenopausal women.

Histologic material from 42 patients with endometrioid carcinomas of the ovary was reviewed. Ovarian endometriosis was present in 11 cases (26%) and 8 of these patients were postmenopausal. The exact site of transition from benign to malignant epithelium was observed in 4 cases. The clinical characteristics of patients with associated endometriosis were not significantly different from those without this finding except that endometriosis was present only in patients with Grade 1 or Grade 2 carcinomas. These data suggest that ovarian endometriosis in the postmenopausal patient has the potential to undergo malignant transformation and, when detected, should be removed surgically.

Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography.

From November 1987 to January 1991, 1300 postmenopausal women underwent screening with transvaginal sonography (TVS). Women eligible for screening were all asymptomatic with no known ovarian tumors. Ovarian volume was calculated using the prolate ellipsoid formula, and a value in excess of 8.0 cm3 was considered abnormal. Ovarian abnormalities were detected in 33 women (2.5%), and 27 underwent exploratory laparotomy. Ovarian tumors were noted in all 27 patients, including 2 primary carcinomas and 14 serous cystadenomas. The two women with ovarian carcinomas had normal results of pelvic examinations and normal serum CA-125 levels. Both women had Stage I disease, and are alive and well after conventional therapy. TVS was time efficient, easy to perform, and well-accepted by patients. Currently, there are more than 3000 patient years of follow-up in the screened population, and there have been no deaths due to ovarian cancer. A multi-institutional trial to determine the efficacy of TVS as a screening method for ovarian cancer is indicated.

Malignant schwannoma in pregnancy.

We report a case of malignant schwannoma on the distal forearm in a pregnant woman with neurofibromatosis. The problems of managing concomitant pregnancy and this particular maternal malignancy are discussed, leading toward a favorable maternal-fetal outcome.