Sonographic findings of a large vulvar lipoma.

Lipomas of the vulva are rare benign tumors that consist of mature fat cells often interspersed with strands of fibrous connective tissue. They arise from the vulvar fatty pads and present as soft, multilobulated subcutaneous neoplasms. Histological examination reveals a thin capsule surrounding a lobular proliferation of lipocytes. Liposarcomas of the vulva have been described rarely. We present the sonographic findings of a large lipoma of the vulva, and demonstrate the contribution of topical application of a high-frequency transvaginal transducer in depicting lobular structural features, characteristic of this soft tissue tumor.

Transvaginal sonographic findings of a large intramural uterine hematoma associated with iatrogenic injury sustained at termination of pregnancy.

We report a case in which a patient presented with severe right lower abdominal pain associated with nausea and vomiting 3 days after termination of pregnancy. Transvaginal ultrasonography showed a large intramural mass in the anterior aspect of the lower segment of an acutely retroflexed uterus. Computed tomography and magnetic resonance imaging findings were consistent with an intramural hematoma as a result of iatrogenic injury sustained during the preceding termination of pregnancy. The patient was managed expectantly. Systematic review of the literature confirmed that this is the first report of sonographic findings associated with an intramural uterine hematoma some days after the injury sustained at termination of pregnancy. This case supports utilization of real-time ultrasound guidance during intrauterine surgery of selected cases to decrease procedure-related morbidity.

Transient bilateral ovarian enlargement associated with large retroperitoneal lymphoma.

Bilateral ovarian enlargement may reflect benign or malignant processes of the ovary. Benign causes of ovarian enlargement include luteomas, tumors such as mature cystic teratomas, fibrothecomas, cystadenomas and rare conditions including capillary hemangioma and massive edema of the ovaries. Ovarian malignancies include epithelial, stromal and germ-cell tumors. Primary malignancies that may exhibit metastases to the ovaries include gastrointestinal, breast and soft tissue tumors such as lymphoma. We present an unusual case in which a patient presenting with weakness and mild lower abdominal and pelvic pain was noted at sonography to have bilaterally enlarged ovaries with features similar to those of massive ovarian edema as described previously, which has been associated with venous and lymphatic obstruction. Subsequent computerized tomography (CT) imaging depicted a large retroperitoneal tumor, CT-guided biopsy of which revealed diffuse large B cell lymphoma. The patient responded well to chemotherapy with significant shrinkage of the tumor, and reappearance of normal findings on ovarian sonography. This case demonstrates that bilaterally enlarged ovaries may be the first clinical evidence of a large retroperitoneal tumor and that in such cases CT imaging may be warranted.

Erythropoietin administration during primary treatment for locally advanced cervical carcinoma is associated with poor response to radiation.

The purpose of this study was to determine whether the use of recombinant erythropoietin (r-EPO) during treatment for locally invasive carcinoma of the cervix affects recurrence rates, disease-free survival, and overall survival. Retrospective analysis of outcomes of patients with locally advanced cervical cancer treated with radiation and concurrent chemotherapy between January 1997 and July 2004 was performed. Recurrence rates, disease-free survival, and overall survival were calculated using SPSS statistical software. Throughout P < 0.05 was considered significant. Of 68 patients included in this study, 18 patients received erythropoietin during treatment and 50 did not. Patient age, stage, hemoglobin at presentation, and average weekly hemoglobin (AWH) were similar in both groups of patients. The recurrence rate among patients who received r-EPO was 61% compared with 30% among patients who did not receive r-EPO (P = 0.014). Eight of 18 patients (44%) who received r-EPO were alive at last known follow-up compared to 36 of 50 (72%) who did not receive the medication (P = 0.045). Disease-free survival and overall survival were significantly shorter in patients who received r-EPO during treatment (P = 0.028, 0.032). The administration of r-EPO during primary treatment of patients with locally advanced cervical cancer is associated with increased recurrence rate, increased risk of death due to disease, and decreased disease-free and overall survivals.

Laparoscopic management of adnexal masses.

BACKGROUND AND OBJECTIVE: Although laparoscopic surgery for removal of adnexal masses is common, controversy exists about the safety and efficacy of this procedure for patients with malignancies. The aim of this study was to evaluate the effectiveness and safety of laparoscopic surgical treatment for patients with adnexal masses. METHODS: This was a retrospective chart review of one surgeon's experience in managing patients diagnosed with adnexal masses at 2 urban referral teaching hospitals in New York City. We reviewed the charts for 100 consecutive patients who underwent operative laparoscopy for management of adnexal masses between March 4, 1996 and November 9, 1998. Conversion to laparotomy, malignancy rate, complications, length of stay, and blood loss were recorded for each patient. RESULTS: Laparoscopic management was successfully completed for 81 of the 100 patients in this study; however, 19 required conversion to laparotomy. All 81 patients managed laparoscopically had a benign diagnosis, whereas 7 of the 19 patients who underwent laparotomy were diagnosed with malignancy. The median length of stay, estimated blood loss, and operating room time were significantly lower for those treated by laparoscopy alone compared with those converted to laparotomy (2 vs. 7 days; 100 vs. 500 ccs; 130 vs. 235 minutes, respectively; P < 0.05). Though few patients were in the laparotomy group, that data are presented for completeness. A total of 10 complications occurred, 4 in the group of patients managed laparoscopically (2 enterotomies, 1 pneumothorax, and 1 vaginal cuff cellulitis). Six complications occurred in those managed with laparotomy (2 enterotomies, 2 wound infections, 1 pneumonia, and 1 postoperative fever). The indications for conversion to laparotomy were: 7 malignancies (5 ovarian cancers and 2 uterine cancers), 7 dense adhesions, 2 small bowel enterotomies, 1 intraoperative bleeding, 1 secondary to a large uterus (880 grams), and 1 secondary to a large myoma (13 cm x 14.5 cm x 6 cm). CONCLUSIONS: The laparoscopic approach is effective and safe for managing patients with adnexal masses of unknown pathology. Malignancies can be diagnosed accurately, converted to laparotomy, and staged appropriately. Adequate surgical skills along with timely use of frozen sections are required for successful operative management.

Endometriosis with massive ascites.

We present 4 cases of endometriosis complicated by massive ascites from our institution and a review of 27 cases from the literature. In most of these patients, the presence of ascites with its related symptoms in association with pelvic masses suggested a neoplastic disease. However, a large proportion of these women had also classical manifestations of endometriosis, e.g., dysmenorrhea, cul-de-sac nodularities, and exacerbation of ascites and other symptoms during the menses. The response to hormonal therapy including GnRH agonists was often unsatisfactory. Repeat recurrences and severe complications required multiple laparotomies and thoracotomies for associated pleural and pulmonary involvement.

Neoadjuvant chemotherapy in stage IB2 squamous cell carcinoma of the cervix.

To determine the effects of neoadjuvant chemotherapy (NAC) in the management of cervical carcinoma Stage IB2 (tumor diameter > 4 cm), we reviewed 52 surgically treated patients diagnosed between January 1987 and December 1993. There were 20 patients treated with preoperative neoadjuvant chemotherapy and 32 treated by primary radical hysterectomy. Mean tumor diameter was significantly larger in the neoadjuvant, compared with the primary surgery group (6.5 +/- 1.8 vs 5.4 +/- 0.7, P = 0.003). In the NAC group, 5 of 20 patients were treated with three courses of cisplatin, methotrexate, and bleomycin every 21 days, whereas 15 of 20 patients received three courses of cisplatin, vincristine, and bleomycin every 10 days. Postoperative adjuvant therapy consisting of either radiation or chemotherapy was employed in 13/20 patients (65%) in the NAC group and 20/32 patients (63%) in the primary surgical group. At a median follow-up of 52.5 months, 4/20 patients (20%) in the NAC group recurred vs 11/32 (34%) in the primary surgery group. The overall response rate to NAC was 90%, with 2/20 complete clinical responders and 16/20 partial responders. High-risk pathologic factors were less commonly observed in the NAC group when compared with the primary surgical group with the incidence of nodal metastases, positive vascular space involvement, undiagnosed parametrial disease, and > or = 75% depth of invasion observed in 10.0% vs 37.5%, 20.0% vs 46.9%, 0.0% vs 15.6%, and 30.0% vs 68.8%, respectively. No differences were noted in operative time or blood loss. Cox proportional-hazards analysis indicated that the most significant prognostic factor was depth of invasion. Although the patients who received neoadjuvant chemotherapy had significantly larger tumors at baseline, their 5-year survival rate was slightly higher than that of the primary surgery group (80.0% vs 68.7%, P = 0.162). Patients receiving neoadjuvant chemotherapy, despite having significantly larger pretreatment tumors, had fewer high-risk pathologic factors, postoperatively. Although this was a small, nonrandomized study, the relative improvement in pathologic response and long-term outcome associated with neoadjuvant chemotherapy was encouraging. This highlights the need for a prospective randomized clinical trial to establish whether neoadjuvant chemotherapy can significantly improve the long-term outcome of women with Stage IB2 squamous cell carcinoma of the cervix.

Age, substance abuse, and survival of patients with cervical carcinoma.

BACKGROUND: The poor survival of young patients with cervical cancer in a low income, disadvantaged community stimulated an investigation of pathologic and behavioral risk factors. METHODS: The records of 1173 patients with cervical cancer diagnosed in 1967-1988 were evaluated with respect to age, stage, histology, and presenting symptoms. Histopathologic risk factors were evaluated in 196 patients with Stage IB disease treated by initial hysterectomy. Substance abuse behaviors were evaluated for 332 symptomatic patients with Stages IB-III disease diagnosed from 1976 to 1988. RESULTS: There were no significant age-related differences in survival for patients without squamous cell carcinoma or those with Stage IA and asymptomatic Stage IB squamous cell carcinoma. Women age 70 years and older had a poorer survival rate than did younger women with Stages IB-III disease. Symptomatic patients with squamous cell carcinoma younger than age 50 years had a poorer survival than did patients age 50-69 years with Stages IB/IIA, IIB, and III disease. For patients with symptomatic Stage IB tumors, poor prognostic histopathologic factors were distributed equally among women younger than age 50 and those aged 50-69 years. Substance abuse was significantly more prevalent among younger patients, and patients who smoked or abused alcohol or drugs had significantly poorer survival than did nonsubstance abusers. However, in a multivariate analysis of age, stage, and substance abuse, young age remained a significantly poor prognostic factor. CONCLUSIONS: Substance abuse may contribute to poor outcome of young patients with symptomatic squamous cell carcinoma but does not explain adequately their poor survival.

Recurrent cervical intraepithelial neoplasia in human immunodeficiency virus-seropositive women.

OBJECTIVE: To determine the effect of human immunodeficiency virus (HIV) infection on the rate of recurrence of cervical intraepithelial neoplasia (CIN) after standard ablative therapy, and to correlate the degree of immunosuppression with treatment results. METHODS: The clinical courses of 44 HIV-positive women with CIN were compared with those of 125 HIV-negative women. Patients were treated with cryotherapy, laser therapy, or cone biopsy per standard indications and were followed with cytology at regular intervals, with a range of follow-up of 3-43 months. RESULTS: Seventeen of 44 HIV-positive women (39%) developed biopsy-proven recurrent CIN, compared to 11 of 125 HIV-negative women (9%) (P < .01). The distributions of CIN severity, lesion size, and modality of treatment were similar in the two groups. In HIV-negative patients, recurrent CIN was associated with increasing grade, but in HIV-positive patients, recurrence was related to increasing immunosuppression. The mean CD4 count in HIV-positive patients with recurrence was 239/mm3, compared to 367/mm3 in HIV-positive patients who remained free of CIN. Only 18% of HIV-positive patients with CD4 counts over 500/mm3 had recurrence, compared to 45% of those with CD4 counts under 500. There was a trend toward poorer treatment results with the use of cryotherapy in HIV-positive patients. All recurrences occurred in patients whose mode of acquisition of HIV was heterosexual transmission. CONCLUSION: Recurrence rates of CIN after standard treatment in HIV-positive women are high, and recurrence is related to immune status in this high-risk group. Therapeutic strategies that address these treatment failures should be developed for HIV-seropositive women.

Human immunodeficiency virus infection and invasive cervical carcinoma.

BACKGROUND AND METHODS: To determine the relationship between cervical cancer and human immunodeficiency virus (HIV) infection, 84 women of known HIV status with invasive cervical carcinoma were assessed. Sixteen of 84 patients (19%) were HIV seropositive. The disease characteristics, recurrence rates, survival rates, and immune status of 16 seropositive and 68 seronegative women were compared. RESULTS: HIV-infected women with cervical cancer had significantly more advanced disease than those who were not infected with the virus. Only 1 of 16 (6%) HIV-infected women had early-stage surgical pathologic disease compared with 40% in the HIV-negative group. The response to therapy and prognosis were poorer among HIV-infected women, with higher recurrence and death rates compared with uninfected women. The mean CD4 counts, CD4:CD8 ratios, and percentage of CD4 cells were 360/mm3, 0.57, and 26.8% in HIV-infected women compared with 830/mm3, 1.71, and 41.2% in HIV-negative group. The patient's immune status had a significant impact on subsequent disease because only seropositive patients with CD4 counts greater than 500/mm3 had prolonged or disease-free follow-up. Surgery was performed safely in patients with relatively good immune function. CONCLUSIONS: HIV-infected women represent a unique subset of patients with cervical carcinoma that have more aggressive disease and a poorer prognosis. However, positive serostatus alone does not uniformly confer an unfavorable outcome because patients with initial adequate immune status may do well. HIV testing is recommended in all relatively young women with cervical cancer, and unique therapeutic strategies are advocated in women with these two potentially fatal diseases.

Bronchial metastases from ovarian carcinoma. Report of a case and review of the literature.

A patient with ovarian cystadenocarcinoma developed respiratory insufficiency due to bilateral endobronchial metastases, 6.5 years after treatment of the primary tumor. Ovarian cancers frequently metastasize to the pleura and lung parenchyma. Clinically significant bronchial metastases are rare. Only three cases have been reported previously. As in our patient, bronchial metastases tend to occur after a relatively long interval from diagnosis of the primary tumor, and survival may be prolonged after their appearance.

Colposcopic evaluation of human immunodeficiency virus-seropositive women.

To determine the effect of human immunodeficiency virus (HIV) infection on cervical histology, 32 known HIV-seropositive women underwent cervical colposcopic evaluation. All had cervical cytology, colposcopically directed biopsy, and T-cell studies performed. Thirteen of 32 patients (41%) had cervical intraepithelial neoplasia (CIN). Another 14 of 32 patients (44%) had histologic evidence of cervicitis. Abnormal cytology, noted in only three women, suggested CIN in one and inflammatory atypia in two. All (five of five) patients with a clinical diagnosis of AIDS had CIN, compared with 30% (eight of 27) of non-AIDS HIV-positive patients (P less than .05). Patients diagnosed with CIN had significantly lower CD4 cell counts (221/mm3 versus 408/mm3; P less than .06) and CD4:CD8 ratios (0.33 versus 0.62; P less than .02) than those without CIN. Patients with cervicitis had greater T-cell immunosuppression than did those with normal histology. In addition, patients with AIDS were more likely to have higher-grade lesions than were non-AIDS HIV-seropositive patients. Seven of 12 CIN specimens available for analysis by polymerase chain reaction using consensus sequence primers detected human papillomavirus (HPV) DNA, including three patients with three or more HPV types. Our data suggest that abnormal cervical pathology is common among HIV-positive women and that cytologic screening is not predictive of CIN in this population. In addition, the presence and severity of cervical dysplasia correlates with quantitative T-cell function. We strongly recommend that cervical colposcopy be part of the routine management of HIV-seropositive women.

Human immunodeficiency virus infection and cervical neoplasia.

To determine the relationship between human immunodeficiency virus (HIV) infection and cervical neoplasia, the characteristics of invasive and preinvasive cervical disease in 114 patients of known HIV status were assessed. Seven of thirty-seven patients (19%) under age 50 with invasive cervical carcinoma were HIV-positive, including a 16-year-old with stage IIIB disease. HIV-positive patients had more advanced invasive cancer than HIV-negative patients. Disease persisted or recurred in all HIV-positive patients compared to 37% of HIV-negative patients. In HIV-positive patients, the median times to recurrence and death were 1 and 10 months, respectively. No HIV-positive patient had HIV-related symptoms. The mean T4:T8 cell ratio in HIV-positive patients was 0.49, compared to 1.86 in HIV-negative patients. The mean T4 cell count was 362/mm3 in HIV-positive and 775/mm3 in HIV-negative patients. Colposcopic evaluations of the lower genital tract of 77 patients with abnormal smears revealed higher-grade cytology and histology in 25 HIV-positive than in 52 HIV-negative patients. HIV-positive patients had significantly more multifocal/extensive lesions, multisite involvement, perianal involvement, evidence of human papillomavirus (HPV) infection, and associated gynecologic infections than HIV-negative patients. In areas at high risk for HIV infection, we must anticipate a high prevalence of HIV seropositivity in women with invasive cervical cancer. In the HIV-infected, cervical cancer is of advanced stage and responds poorly to therapy. Intraepithelial neoplasia in HIV-positive patients may be of higher grade than in HIV-negative patients, with more extensive involvement of the lower genital tract.