Progression-free interval in ovarian cancer and predictive value of an ex vivo chemoresponse assay.

The study objective was to determine the effectiveness of a phenotypic chemoresponse assay in predicting response to chemotherapy measured by progression-free interval (PFI) in a retrospective series of ovarian cancer patients whose tumor specimens had been tested with the ChemoFx assay. A statistically significant correlation between assay prediction of response and PFI was observed in 256 cases with an exact or partial match between drug(s) assayed and received. In 135 cases with an exact match, the hazard ratio for progression of the resistant group was 2.9 (confidence interval [CI]: 1.4-6.3; P < 0.01) compared to the sensitive group and 1.7 (CI: 1.2-2.5) for the intermediate compared to the sensitive group. The median PFI for patients treated with drugs assayed as resistant was 9 months, 14 months for those with drugs assayed as intermediately sensitive, and PFI had not been achieved for those with drugs assayed as sensitive. These data indicate that the ChemoFx assay is predictive of PFI in ovarian cancer. As the majority of ovarian cancers display different degrees of response to different chemotherapy agents ex vivo, the incorporation of assay information into treatment selection has the potential to improve clinical outcomes in ovarian cancer patients.

Laser surgery in gynecologic oncology.

In the treatment of premalignant epithelial cancers of the female lower genital tract, the CO2 laser beam is used with precision through a surgical microscope for tissue ablation and excision. Intra-abdominal vaporization of abnormal tissues can be performed endoscopically through fiberoptics. Surgical lasers provide thermal scalpels for hemostatic excision of malignant lesions. Photodynamic therapy is applied in the treatment of isolated malignancies persistent after conservative treatment. Surgical laser systems are important tools in the treatment of gynecologic malignancies.

Prognostic factors and the significance of cytologic grading in invasive squamous cell carcinoma of the vulva: a clinicopathologic study.

Clinical staging, tumor size, histologic differentiation, cytologic grading, depth of stromal invasion, and vascular channel involvement by tumor cells were studied in 42 patients with invasive squamous cell carcinoma of the vulva who were treated with radical vulvectomy and inguinal-femoral lymphadenectomy. All parameters were found to correlate well in predicting groin node metastasis. Cytological grading was found to be more significant compared to histologic grading in regard to nodal metastasis (P less than 0.02). No patient with cytologic or histologic grade 1 tumor and less than 5 mm stromal invasion was found to have nodal metastasis.

Significance of lymphoplasmocytic infiltration around tumor cell in the prediction of regional lymph node metastases in patients with invasive squamous cell carcinoma of the vulva: a clinicopathologic study.

Histologic material from 42 patients treated for invasive squamous cell carcinoma of the vulva was studied to determine the prognostic significance of lymphoplasmocytic infiltration around tumor cells in the prediction of regional lymph node metastases. No correlation was found between lymphoplasmocytic infiltration and nodal metastasis with respect to degree of tumor differentiation, stage of disease, and vascular channel involvement. The presence or absence of lymphoplasmocytic infiltration around tumor cells appears to have no prognostic value in predicting nodal metastases.

Comparison of wound healing between chopped mode-superpulse mode CO2 laser and steel knife incision.

The healing of surgical incisions made with the steel knife and CO2 laser chopped wave mode (ChW) or rapid superpulse (RSP) mode were compared using histologic parameters and breaking strength of the scars on postoperative day 14. Using a miniature pig model the Sharplan 1100 laser incisions were made with an average power of 15 W and power density of 7.68 kW/cm2. Histological sections on postoperative day 14 revealed the knife scar measured .49 mm, was hypocellular, and contained visible bundles of collagen fibers. Both CO2 laser scars were less mature, the ChW scar measured 1.04 mm, the RSP scar measured 1.37 mm, and both contained cellular granulation tissue without visible collagen fibers. The breaking strength of the scars was measured with a tensiometer. Laser wounds were weaker than the knife wound. Scheffe test for variables was significant at P = .01 between the two laser modes and the knife. No significant difference was noted in the breaking strengths of incisions made with the chopped mode and superpulse mode.

Photodynamic therapy of gynecologic neoplasms after presensitization with hematoporphyrin derivative.

Five patients with various gynecologic neoplasms were treated with photodynamic therapy using 630-nm light delivered from an argon dye laser system following the intravenous injection of hematoporphyrin derivative (HpD). A patient with multifocal squamous cell cancer of the vagina had no evidence of disease 15 months after her first photodynamic therapy treatment. Autopsy nine months after the first treatment of another patient with multifocal invasive cancer of the vagina and parametrium showed no evidence of tumor on the surface of the vagina. Eight months after treatment of an 8 X 12 cm area of Bowen's disease of the vulva and thigh, there was no evidence of disease. Vaginal bleeding from breast cancer metastatic to the endometrium was controlled by one treatment until the patient expired five months later from her disease. Adenocarcinoma metastatic to the vaginal cuff showed partial response when vaginectomy was performed five weeks after photodynamic therapy.

The neodymium:YAG laser in the treatment of gynecologic malignancies.

The Nd:YAG laser has been used for tumor volume reduction of recurrent gynecologic malignant tumors after previous radiation therapy. The localization of the tumor did not allow conventional surgical resection or surgery was contraindicated because of severe medical problems. Hemorrhage caused by recurrent tumor was controlled by tissue coagulation. The laser beam was delivered by means of a handpiece using the Model 8000 of the Molectron Medical Corporation. A power of 40 to 100 W was used with the maximal pulse duration of 9.9 sec and multiple pulse irradiation. The total energy ranged between 620 and 13.105 Ws. Good palliation was achieved in patients with hemorrhaging tumors of the cervix and ovary metastatic to the vagina.

Endometrial carcinoma in women 40 years of age or younger.

Adenocarcinoma of the endometrium in patients 40 years of age or younger is rare and accounts for 2.9% of all endometrial cancers diagnosed in the study community. However, the diagnosis of malignancy was confirmed in only 32 of 54 patients (59.2%) with pathologic material available for review. None of the 32 patients had Stein-Leventhal syndrome or was receiving sequential oral contraceptives. Obesity was found in only 37.5%, nulligravidity in 37.5%, and hypertension in 25%. In 81%, the presenting symptom was abnormal vaginal bleeding, and 6 patients (19%) had coexisting ovarian neoplasms (4 endometrioid carcinomas, 1 mucinous cystadenocarcinoma, and 1 adenocarcinoma arising in a cystic teratoma). Atypical endometrial hyperplasia, previously interpreted as well-differentiated adenocarcinoma, was diagnosed in 11 of 22 patients. The pathologic criteria for establishing a diagnosis of atypical endometrial hyperplasia and distinguishing it from well differentiated adenocarcinoma of the endometrium are emphasized. Thirteen of 32 patients received no radiation therapy and none developed pelvic recurrence or metastatic tumor. The 2 deaths from tumor were in patients with stage 3 ovarian cancer, and no patients died of endometrial carcinoma. The current policy is to treat patients with atypical endometrial hyperplasia and well-differentiated adenocarcinoma (clinical stage I, pathology confirmed) by hysterectomy without irradiation treatment. Because of 6 of the 32 patients (19%) had coexisting ovarian neoplasms, careful examination of the adnexa at the time of clinical staging is emphasized.

Microinvasive carcinoma of the vulva: a clinicopathologic evaluation.

Two types of neoplasms described as superficially invasive or microinvasive carcinoma of the vulva were identified. One type, which can be treated by conservative surgery, is commonly associated with extensive overlying intraepithelial neoplasia. Usually 1 focus of microinvasion, but occasionally more invades less than 2 mm into the underlying stroma. The infiltrating cells comprise 1 or more isolated cords, and confluency is never present. The second and less common form tends to metastasize early to lymph nodes and should be treated by a radical approach. This type is seldom associated with overlying intraepithelial neoplasia. It tends to be poorly differentiated and is confluent. In this series, 2 of 3 patients with confluent microinvasion had metastases to the lymph nodes, but none of 15 patients with nonconfluent microinvasion developed metastases.

Extraperitoneal surgical approach to the pelvis after radiation therapy or radical surgery.

Use of extraperitoneal surgical procedures in patients who have developed a retroperitoneal surgical problem after radiation therapy, primary radical surgery, or both has the advantages of excellence of exposure, shortness of operating time, isolation of infections, and avoidance of bowel manipulation. The surgical technique was adjusted to each individual patient's needs in the 21 patients involved in this study. Intensified pelvic fibrosis with constriction of ureter and pelvic vessels postoperatively was experienced in one patient. The surgical exploration should remain confirmed to the area of interest.

Laser surgery in gynecology.

More experience and time are required to determine the advantages of laser surgery in gynecology. For precision surgery through the colposcope, the carbon dioxide laser beam appears to be useful in the control of neoplastic lesions of the vaginal mucosa and possibly of the cervix uteri. Tumor volume reduction through laser vaporization, especially when a recurrent tumor is attached to the bony pelvis, is an outstanding advantage. Adhesiolysis during myomectomy and reconstructive surgery of the fallopian tubes might be facilitated by the laser beam. Laser surgery on the vulva, both colposcopically directed and grossly with the CO2 laser scalpel, might prove to be important for the treatment of various lesions. Detailed technical knowledge, rigid safety precautions, and judicious clinical considerations are essential for competent laser surgery.

PIP: Carbon dioxide laser in gynecologic surgery utilizes 2 different operating mechanisms. One model uses the optical system of a colposcope, a specially designed operating microscope through which the laser beam is used to destroy microscopic lesions with high precision in the female genital tract. The focused laser beam is used as a thermal scalpel to perform surgical procedures. In short-term clinical follow-ups, thermal destruction by electrocautery or cryosurgery of well-delineated epithelial neoplastic lesions had been achieved with acceptable results. Destruction of entire transformation zone can be usually achieved, and depth of tissue destruction can be extended to the base of endocervical glands in a depth of about 5 mm. Advantage of thermal tissue destruction is that it can be done as an outpatient procedure, while a definite drawback is the lack of histopathologic diagnostic evaluation of the entire lesion treated; in the hands of inexperienced clinicians, this can lead to the masking of an invasive carcinoma and hence disastrous results. Another advantage is tumor volume reduction through laser vaporization, especially when a recurrent tumor is attached to the bony pelvis. Laser surgery are also applicable in adhesiolysis during myomectomy and reconstructive surgery of the fallopian tubes. Laser surgery on the vulva may be useful in the treatment of various lesions. Competent laser surgery necessitate technical knowledge; rigid safety precautions; and judicious clinical considerations.

Radiation-induced bladder tumors.

A recent 25-year experience with patients treated for carcinoma of the uterine cervix who subsequently had bladder tumors is presented. Of the 3,091 patients treated 2,674 had received radiotherapy and 8 suffered vesical malignancies of varied histopathological type 6 months to 20 years after irradiation. This incidence rate is 299.9 per 100,000, which is 57.6 times that of the general female population. Benign radiation reactions of the bladder and the possible etiology of radiation-induced bladder cancers are discussed.

Extraperitoneal para-aortic node dissection through an upper abdominal incision.

A surgical technique for para-aortic lymph node evaluation for metastatic tumor by the extraperitoneal approach is described. The procedure is devised to avoid gastrointestinal complications frequently found after transperitoneal evaluation of the para-aortic area followed by extended field irradiation. The surgical procedure was performed in 20 patients. Nine patients treated with 6000 rads extended field irradiation remained without gastrointestinal complications after 3 to 16 months of follow-up.