Xanthogranulomatous tubo-ovarian abscess resulting from chronic diverticulitis.

We report a case of xanthogranulomatous tubo-ovarian abscess which was preoperatively suspected to be an adnexal neoplasm. With foreign body material found in the abscess wall and vegetable fiber in the tubal lumen, a previously treated chronic diverticulitis was the presumed cause. Culture studies showed polymicrobial isolates which included Escherichia coli, an enteric pathogen. After surgery, administration of antibiotics, and revision of delayed subcutaneous wound healing, the patient is reportedly well.

All-trans retinoic acid and interferon-alpha-2a in patients with metastatic or recurrent carcinoma of the uterine cervix: clinical and pharmacokinetic studies. New York Gynecologic Oncology Group.

BACKGROUND: Recent clinical trials with a combination of interferon (IFN alpha) and 13 cis-retinoic acid resulted in high response rates among women with locally advanced and metastatic carcinoma of the uterine cervix. The authors sought to amplify these observations by employing the isomer of 13 cis-retinoic acid, all-trans retinoic acid (tRA), in combination with IFN alpha. METHODS: Sequential clinical trials were initiated by the New York Gynecologic Oncology Group to test the combination of tRA and IFN alpha in women with metastatic or recurrent carcinoma of the cervix who had failed primary therapy. IFN alpha was administered at 6 MU subcutaneously 3 times per week. In the first trial, tRA was administered at 50 mg/m2 orally 3 times per day on a daily schedule (daily regimen), whereas in the second trial, tRA was administered at the same dose 3 times per day, but only on Days 1-3 each week (intermittent schedule). Clinical outcomes included response to therapy and survival. Plasma pharmacokinetic studies of tRA were performed in both trials to assess the effects of different schedules on plasma levels of the drug. RESULTS: Fourteen women with metastatic or recurrent squamous cell carcinoma of the cervix were enrolled in the daily trial and 12 women in the intermittent trial. There was no clinical activity for either regimen, and both studies were terminated according to an early stopping rule. Because tRA has been reported to induce its own metabolism, plasma levels of tRA were measured on Days 1, 8, and 28. The change in the area under the time versus tRA concentration curve (AUC) was significantly different between the two groups. The average AUC on Day 8 was 14% of that observed on Day 1 for the daily treatment group; in contrast, it was 107% on Day 1 in the intermittent treatment group. In 6 of 8 patients studied in the daily trial, the AUC decreased at least 60% by either Week 2 or Week 4. In contrast, in the intermittent trial, only 3 of 9 patients experienced >60% decrease in plasma levels of the drug at either Day 8 or Day 28. CONCLUSIONS: The combination of tRA + IFN alpha was inactive in patients with advanced carcinoma of the cervix when employed at these doses on either the daily or intermittent schedule. The failure of activity of this regimen did not result from induction of metabolism of tRA, suggesting that intrinsic mechanisms of resistance to tRA at the cellular level may be of greater importance.

Coexistent atypical polypoid adenomyoma and endometrial adenocarcinoma.

Atypical polypoid adenomyoma (APA) is a rare entity that is believed to follow a benign course. We report a case of APA with coexistent endometrial adenocarcinoma. The example raises the possibility that APA may progress to endometrial adenocarcinoma in some cases.

Endometrioid carcinoma of the fallopian tube: pathology and clinical outcome.

A case of endometrioid carcinoma of the fallopian tube is reported with histologic description and clinical follow-up of four years. Only two other cases have been documented previously. This case is thought to be unique as the carcinoma arose in a benign endometrioid tumor. Inferences concerning Mullerian duct expression and neoplasia are reviewed.

Responsiveness of L-S ratio of the amniotic fluid to intra-amniotic administration of thyroxine. Role of fetal age.

Since 1982 we have accelerated fetal maturation with intra-amniotic thyroxine (T4) in more than 140 patients. The purpose of this analysis was to determine the rate of change of the ratio of lecithin to sphingomyelin (L/S) after administration of T4 at different gestational ages, and to compare the responses to the first and the second administration of T4. Fifty-nine cases in which administration of T4 was continued for 2 weeks or more, and in which at least 3 determinations of L/S had been performed, were identified. Gestational age of the fetus at the inititiation of treatment ranged from 26 to 31 weeks (mean 29.3 weeks). Thyroxine was administered weekly in 200 to 500 mcg doses. Administration of T4 prior to the 27th week did not change the L/S. From the 27th and 31st week of gestation, the slope of the L/S, after the initial dose of T4 increased from 0.33/wk to 1.05/wk. In contrast the slope of the untreated patients changed little reaching a maximum of 0.22 at the 33 week. L/S greater than 2 was observed in 80% of cases after 2 weeks of therapy, when it had been initiated after the 26th week. The response to the second dose was about twice that of the first in fetuses less than or equal to 30 weeks, but was similar to that seen after the initial dose in fetuses greater than 30 weeks. Phosphatidylglycerol (PG) was detected in amniotic fluid in 51% of cases after 2 weeks of treatment, and in 6 instances as early as at the 30th week. Responsiveness of L/S to T4 treatment of the fetus is a function of gestational age and of prior exposure to T4.

Acceleration of fetal maturation with intra-amniotic thyroxine in the presence of maternal malignancy.

Acceleration of fetal maturation with intra-amniotic administration of thyroxine was employed in eight patients in whom preterm delivery was necessary because of malignant disease of the mother. Thyroxine (200 mcg to 500 mcg) was given at weekly intervals starting at the 27th to 32nd week of gestation until the L-S ratio exceeded 2.0. The fetuses were delivered between the 29.4 and 34.0 week. None of the newborns suffered from respiratory distress syndrome, and three newborns were cared for in the regular nursery. Thyroxine-induced acceleration of fetal maturation and pre-term delivery permits earlier initiation of antineoplastic and radiation therapy without exposing the fetus to the hazards of maternal therapy and those of prematurity.

Single cause for initiation of labor and toxemia: a hypothesis.

A hypothesis is presented that states that the decline in oxygen tension (PO2) in the intervillous space causes both toxemia (preeclampsia-eclampsia) and the initiation of labor. The trophoblast is identified as the monitor of the fetal PO2 and as the source of substances that are released into the maternal circulation stimulating the myometrium, the heart, the vascular smooth muscle, and, perhaps, the brain. In the presence of normal trophoblast the release takes place only when the PO2 in the intervillous space decreases to a level at which the fetus should be expelled from the uterus to avoid intrapartum hypoxia. Near term, the myometrium is the most responsive site to the released substances, and stimulation of the heart and systemic vasculature is observed only infrequently. With release of these substances, intrapartum toxemia results. Toxemia before onset of labor is created by hypoxia of the trophoblast in the presence of a nonresponsive myometrium to materials released. A small placenta, compression of the intervillous space by villous edema, and avulsion of spiral arterioles are the main causes of the premature decline of intervillous space PO2, leading to toxemia. Postpartum toxemia is produced by the retained (extraplacental) trophoblast, perhaps facilitated by the rapid clearance of progesterone.

Papillary adenocarcinoma in the endometrium.

Papillary adenocarcinoma should be regarded as a subtype of endometrial carcinoma with poor prognosis. Review of 22 cases indicates an older average age than is found with the usual endometrioid type, with frequent surgical upstaging, deep myometrial invasion, nodal and adnexal involvement, positive peritoneal washings, upper abdominal recurrence, and poor response to conventional treatment. These observations suggest a different natural history from that of the more common histologic subtypes of endometrial carcinoma. Management should include initial exploration of the entire abdominal cavity to determine the true extent of the disease, and treatment must include the upper abdomen.

Prognostic factors: cisplatin regimens for patients with ovarian cancer after failure of chemotherapy.

For 129 ovarian cancer patients failing prior chemotherapy, overall clinical response rates were: 21% with cisplatin, 36% with cisplatin plus doxorubicin, 52% with cyclophosphamide added to the two drugs, and 44% with hexamethylmelamine added to the three drugs. Median survival was six or seven months in each trial. Twenty-five percent of the patients survived nine months with cisplatin and 14 to 16 months with each of the three combinations. Characteristics associated with best rate of response included: performance status 1 (completely ambulatory), age greater than or equal to 50, residual tumor less than or equal to 5 cm, and two or less prior cytotoxic drugs. In multivariate analyses, performance status dominated, although age and possibly treatment (cisplatin versus others) were significant. With performance status removed from the model, all of the remaining factors became significant. Factors associated with best survival included: performance status 1, tumor size less than or equal to 5 cm, and complete or partial response. In a multivariate analysis for survival, performance status entered the model. In a series of analyses with performance status removed, tumor size or response entered the model. These findings provide reasons to study both treatment with cisplatin before disease progression reduces the number of favorable characteristics and systematic second attempts at debulking surgery.

Cytologic diagnosis of Bartholin's gland adenocarcinoma.

An adenocarcinoma of Bartholin's gland was diagnosed by a smear of a swollen lesion of the left vulva, with confirmation on the subsequent surgical specimen. This appears to be the second such case in which the diagnosis was established by cytologic examination of the smear. This rare tumor should be considered in patients presenting with vulvar swellings; cytologic examination can be useful in its early diagnosis, as demonstrated by this case.

Endocrine aspects of human uterine sarcoma: a preliminary study.

The biologic effect of estrogen and progesterone in human uterine sarcoma is poorly understood in comparison to that of endometrial adenocarcinoma. In an attempt to elucidate the endocrine status of these tumors, we have investigated the ability of these tumors to synthesize estrogen by measuring the aromatase activity and studied the effect of aromatase inhibitors on the activity. In addition, the effect of estrogen and progesterone on aromatase activity and the growth pattern of these tumors were studied in cell culture and athymic mice systems. Aromatase activities in eight uterine sarcomas ranged from 0.7 to 37 fmol/hr X mg protein, which were within the range or higher than the activity found in normal proliferative endometrium (0.5 to 3 fmol/hr X mg of protein, means = 1.6, n = 10). These results indicate that uterine sarcomas are capable of producing estrogen. However, the enzyme activity showed no correlation with the morphology of tumors or the age of patients. Results from the kinetic studies of aromatase activity in one of the uterine sarcomas indicated that 19-nortestosterone, testolactone, and aminoglutethimide (the most effective one) inhibited aromatase activity. In addition, induction of aromatase activity in two uterine sarcomas was investigated in cell cultures. Progesterone caused an eightfold increase in activity in a sarcoma that was estrogen and progesterone receptor positive but had no effect in a tumor that was estrogen and progesterone receptor negative. The growth rate of two estrogen/progesterone receptor-negative uterine sarcomas was studied in cell culture and in athymic mice. Progestin, but not estrogen, reduced the growth rate in both systems; 30 nmol/L of estrogen had no effect on the growth rate. In summary, we have found that human uterine sarcoma is able to synthesize estrogen. Progesterone is able to induce the aromatase activity in estrogen/progesterone receptor-positive tumors, and progesterone also suppresses the tumor growth rate in estrogen/progesterone receptor-negative tumors. These results suggest that a select group of uterine sarcomas is sensitive to steroid hormone and that progesterone may be potentially beneficial for therapeutic treatment of select uterine sarcomas.

Prenatal diagnosis of dyssegmental dwarfism.

Fetal ultrasound evaluations at 18 weeks gestation on two consecutive pregnancies of a woman who previously gave birth to a stillborn female affected with dyssegmental dwarfism, resulted in accurate diagnoses of unaffected and affected fetuses. Marked disorganization of vertebral bodies and associated encephalocele found in two affected cases in this family are consistent with the original observation of this new syndrome as two major aspects which differentiate it from other forms of lethal dwarfism.

Endometriosis of the omentum and borderline ovarian malignancy.

A symptomatic pelvic-abdominal mass in a 29 year old female was found to be bilateral ovarian serous cystadenomata of borderline malignancy. In addition, a thickened region of the omentum was removed and proved to be endometriosis. Endometriosis of the omentum is rarely reported and this case may mark a unique association with ovarian serous cystadenoma of borderline malignancy. The possible origins of omental endometriosis include metastasis and metaplasia. Omental endometriosis is rare and should be included in the differential diagnosis of omental tumors.

Papillary metaplasia of the endometrium: clinical and histopathologic considerations.

The clinical presentation and histopathology of three cases of papillary metaplasia of the endometrium are reported. This lesion is usually found with unopposed estrogen stimulation. Two of these patients were perimenopausal, and one was postmenopausal. In two of these patients chronic endometritis was found. Papillary metaplasia of the endometrium is infrequently cited and must be recognized as a benign entity.