Conservative management of isolated posthysterectomy fever.

OBJECTIVE: To demonstrate that an isolated fever in the absence of other signs or symptoms of infection following hysterectomy does not require empiric antibiotics and laboratory tests. METHODS: Retrospective analysis of all the charts of patients who had a hysterectomy from July 1995 to December 1996 at our institution. Patients with a postoperative temperature > 38 degrees C had a physical examination. If the examination was normal, no studies were ordered, and antibiotic therapy was not initiated. If a patient was febrile after 72 hours postoperatively, laboratory studies and radiographic tests were ordered. If the results were negative, the patient did not appear septic, and physical examination was normal, no antibiotics were given. Outcomes were measured by comparing patients with postoperative infections and fever to those without infections. RESULTS: Of 132 patients, 112 were included in the study. Seventy-two hysterectomies were abdominal and 40 vaginal. Postoperative fever during the first 72 hours following hysterectomy occurred in 51/112 (46%) patients. Clinically significant infection was documented in seven patients, all of whom manifested signs and symptoms of infection > 72 hours postoperatively. CONCLUSION: Postoperative fever in the first 72 hours after hysterectomy is common and nonspecific. If a febrile patient does not show any other signs or symptoms of infection, it is safe to forego routine laboratory and imaging studies as well as therapeutic antibiotics.

Primary peritoneal carcinoma presenting on routine papanicolaou smear.

BACKGROUND: Primary peritoneal carcinoma is an uncommon disease, characterized by peritoneal carcinomatosis without other identifiable primary tumor. It typically presents resembling ovarian cancer, with abdominal pain and distention and in an advanced stage. We report a unique presentation of this disease. CASE: A 76-year-old woman had severe glandular dysplasia on a screening Papanicolaou smear. An ectocervical lesion was biopsied, revealing moderately differentiated adenocarcinoma. Cervical stenosis prevented sampling of the endocervix and endometrium. Colonoscopy and mammography did not reveal malignancy. Total abdominal hysterectomy with bilateral salpingo-oophrectomy was performed. Surgery revealed surface implants on the pelvic organs, with minimal involvement of the ovaries. Histologic examination revealed adenocarcinoma with papillary serous differentiation. Surgical and microscopic findings were consistent with a diagnosis of primary peritoneal carcinoma. CONCLUSION: Primary peritoneal carcinoma usually presents in a manner similar to that of ovarian cancer, but atypical presentations also occur. While a Papanicolaou smear suggestive of carcinoma usually represents a primary cervical malignancy, this case serves as a reminder that other metastatic malignancies should be considered.

Recurrent invasive adenocarcinoma after hysterectomy for cervical adenocarcinoma in situ.

BACKGROUND: Unlike its squamous counterpart, therapy for cervical adenocarcinoma in situ with positive endocervical cone margin remains controversial. CASE: A 52-year-old gravida 2, para 1,0,1,1, presented with vaginal bleeding. Gynecologic history was significant for cervical cold knife conization with a positive endocervical margin and endocervical curettage with atypical endocervical cells. Repeat cone biopsy was considered unsafe given the large initial cone specimen. An extrafascial hysterectomy was performed 5 weeks later and pathology confirmed a disease-free cervix. Pap smear performed 1 year later was interpreted as recurrent adenocarcinoma but later downgraded to inflammation. Inspection and random biopsies of the vaginal cuff revealed only inflammation. Two subsequent Pap smears also returned inflammation. Seventeen months after the hysterectomy physical examination revealed a 2 x 3-cm smooth mass at the vaginal cuff. Biopsy revealed invasive adenocarcinoma. The patient underwent an upper vaginectomy followed by postoperative pelvic radiation. CONCLUSION: This case suggests that despite extrafascial hysterectomy for presumed adenocarcinoma in situ of the cervix, a residual focus could remain and present later as invasive adenocarcinoma.

Signet ring breast carcinoma metastases limited to the endometrium and cervix.

Breast cancer metastatic to the cervix and uterus in the absence of extrapelvic foci is a rare finding in the medical literature. Signet ring breast carcinoma is also an unusual neoplasm. We present an asymptomatic 71-year-old woman 2 years status-post modified radical mastectomy for signet ring carcinoma who was found to have metastatic lesions to the cervix and endometrium at the time of a routine gynecological examination. Bone scan as well as computerized tomography of the chest, abdomen, and pelvis failed to locate other metastatic sites. We believe this to be the only reported case of signet ring breast carcinoma metastatic solely to the uterus and cervix. The patient's lack of recent pelvic examination highlights the need for continued gynecological evaluation in patients with breast cancer.

Intraoperative autologous blood collection and autotransfusion in the surgical management of early cancers of the uterine cervix.

OBJECTIVES: To evaluate intraoperative autologous blood collection with autotransfusion (Cell Saver) with respect to patient acceptance, risk of tumor cell co-transfusion, and risk of recurrence in patients undergoing radical hysterectomy for cervical cancer. METHODS: All patients explored for radical hysterectomy between August 1991 and July 1994 were offered the use of intraoperative autotransfusion. Clinical-pathologic and transfusion-related characteristics were compared for a group of historic controls surgically treated for similar disease. The risk of tumor cell co-transfusion was assessed intraoperatively with peritoneal cytology before blood collection, and postoperatively with Cell Saver blood cytology. RESULTS: Ninety-eight patients were offered enrollment; four declined Cell Saver use, and 71 were acceptable for analysis. Thirty-one women (mean estimated blood loss 1338 mL) were reinfused with their own blood collected in the Cell Saver, whereas 40 patients (mean estimated blood loss 631 mL) were not autotransfused. There was no significant difference in preoperative hemoglobin concentration between groups. Cell Saver use significantly reduced the need for homologous transfusions, intraoperatively (P < .001) and postoperatively (P = .02). Historic controls (mean operative blood loss 1743 mL) were nearly four times more likely to have been transfused and three times more likely to have been transfused postoperatively than was the auto-transfused Cell Saver group. The mean hemoglobin concentration at discharge was lower in the autotransfused group, 9.3 g/dL, than in the historic controls, 10.8 g/dL. Nontransfused Cell Saver blood and all peritoneal cytologies were negative for tumor cells. Three pelvic recurrences, but no disseminated disease, have been noted over a mean follow-up of 24 months: one in the autotransfused group and two in the group in which the collected blood was discarded. CONCLUSION: Cell Saver use is well accepted by patients, decreases the need for homologous transfusions, and does not appear to co-transfuse tumor cells.

Evaluation of hyperbaric oxygen as a chemosensitizer in the treatment of epithelial ovarian cancer in xenografts in mice.

BACKGROUND: Resistance to chemotherapy is common in bulky hypoxic tumors such as epithelial ovarian cancer. Hyperbaric oxygen (HBO) oxygenates hypoxic tissues and promotes neovascularization. These unique properties of HBO may help overcome chemotherapy resistance by increasing both tumor perfusion and cellular sensitivity. This study was undertaken to determine if HBO increases the response of epithelial ovarian cancer to cisplatin chemotherapy. METHODS: In Phase I, 64 nu/nu mice were divided into four groups and subcutaneously inoculated with cells from the A2780 human epithelial ovarian cancer cell line. Group 1 served as controls. Group 2 received weekly intraperitoneal cisplatin (3.15 mg/kg). Group 3 was exposed to HBO (dives) at 2.4 atmospheres absolute pressure for 90 minutes, 7 days a week. Group 4 received both cisplatin and HBO. In Phase II, 72 mice were divided into two groups and similarly inoculated. Both groups received weekly intraperitoneal cisplatin (2.5 mg/kg). Group 1 was not exposed to HBO. Group 2 was exposed to HBO for 5 days a week. RESULTS: Dramatic tumor neovascularization was found in tumors of mice exposed to HBO (P = 0.0001). There was significant (P = 0.014) tumor growth retardation in Phase I for mice receiving both cisplatin and HBO compared with those treated with cisplatin alone. This significance was noted after just two doses of cisplatin but subsequently lost due to reduced numbers of mice. In Phase II, neovascularization was detectable after 10 HBO treatments (2 weeks) and was maximal after 15 treatments (3 weeks). CONCLUSIONS: Hyperbaric oxygen increases vascularity in bulky tumors such as epithelial ovarian cancer. There appears to be a relationship between increased vascularity and enhanced response to chemotherapy that merits further investigation.

What is a normal CA125 level?

CA125 is a coelomic epithelial antigen which is widely used to monitor residual disease in patients undergoing chemotherapy for ovarian cancer. Interpretation of serum CA125 levels has been based on a normal value of 35 U/ml which was derived by screening a young, general population of blood donors which included women with intact reproductive systems. This study addresses the issue of what constitutes a normal serum CA125 level following successful surgical therapy for gynecologic malignancy. Three hundred ninety-three CA125 values were measured in 145 patients after an elapsed time of at least 1 year following completion of surgical therapy for early-stage endometrial or cervical adenocarcinoma. All patients were without evidence of recurrent disease. The mean duration of followup was 4.3 years with a median of 3.7 years. Sixty-seven percent of the CA125 values were less than 10 U/ml; 95% were less than or equal to 20 U/ml. The median value for this patient population was 7.5 U/ml with a mode of 7.1 U/ml. There was no correlation between patient age and CA125 levels. These data suggest that the normal value for CA125 used for patient follow-up after treatment for gynecologic adenocarcinoma needs to be redefined. Our data support an upper limit of normal of 20 U/ml and encourage further study on the clinical impact of this new definition.