Pathology of stage I versus stage III ovarian carcinoma with implications for pathogenesis and screening.

The progression of ovarian carcinoma from stage I when it is confined to the ovaries and curable to disseminated abdominal disease, which is usually fatal, is poorly understood. An accurate understanding of this process is fundamental to designing, testing, and implementing an effective screening program for ovarian cancer. Pathologic features of the primary ovarian tumors in 41 FIGO stage I ovarian carcinomas were compared with those in 40 stage III carcinomas. The primary ovarian tumors in stage I cases, when compared with stage III, respectively, were significantly larger (15.4 versus 9.8 cm), were less frequently bilateral (12% versus 75%), more frequently contained a noninvasive component (88% versus 30%), had a higher proportion of a noninvasive component (42% versus 8%), and were more often nonserous (83% versus 20%) (P < 0.001 for all five comparisons). There are significant pathologic differences between the primary ovarian tumors in stage I and III ovarian carcinomas that are very difficult to explain by a simple temporal progression. These findings along with the growing body of literature suggest that early- and advanced-stage ovarian cancers are in many instances biologically different entities. This knowledge may have significant implications for our understanding of the biology of early- and advanced-stage ovarian cancer and therefore on the development of screening strategies for ovarian cancer.

Pretreatment surgical staging of patients with cervical carcinoma: the case for lymph node debulking.

BACKGROUND: The routine use of extraperitoneal surgical staging prior to radiation therapy in patients with bulky or locally advanced cervical carcinoma remains controversial. METHODS: A review was performed of 266 patients with cervical carcinoma who underwent extraperitoneal pelvic and paraaortic lymphadenectomy prior to receiving radiotherapy. Patients were divided into groups based on their lymph node status. Group A had negative lymph nodes; Group B had resected, microscopic lymph node metastases; Group C had macroscopically positive lymph nodes that were resectable at the time of surgery; and Group D had unresectable lymph nodes. All patients received standard radiotherapy utilizing external beam and brachy-therapy. Patients with lymph node metastases received extended field irradiation. Survival probabilities were computed by the Kaplan-Meier product limits method with statistical significance determined by the Mantel-Cox log rank test. RESULTS: Lymph node metastases were detected in 50% of patients. Five- and 10-year disease free survival rates were similar for all patients in Groups B and C. All patients in Group D recurred. There was a 10.5% incidence of severe radiation-related morbidity and a 1.1% incidence of treatment-related deaths. CONCLUSIONS: Pretreatment extraperitoneal staging of patients with bulky or locally advanced cervical carcinoma may afford a survival benefit via the debulking of macroscopically positive lymph nodes without significantly increasing treatment-related morbidity or mortality.

The use of methotrexate and arterial embolization to avoid surgery in a case of cervical pregnancy.

OBJECTIVE: To describe the management of a case of cervical ectopic pregnancy (EP) DESIGN: Case report. SETTING: University-affiliated teaching hospital. PATIENT(S): A 26-year-old woman, gravida 4, para 0-1-2-0 with the diagnosis of a cervical EP. INTERVENTION(S): Systemic methotrexate (MTX) and arterial embolization. RESULT(S): A cervical EP was diagnosed by ultrasonography. The patient was treated with systemic MTX. Vaginal bleeding began 4 days later and was treated with arterial embolization, thus eliminating the need for surgical intervention. The pregnancy resolved and the patient has resumed normal menstruation and again is attempting pregnancy. CONCLUSION(S): Arterial embolization can be used to avoid surgical intervention in cases of cervical EP in which hemorrhage occurs after treatment with chemotherapy.

A simplified method for detubularization in the construction of a continent ileocolic reservoir (Miami pouch).

The development of continent urinary diversions was an important step forward in improving the quality of life of patients undergoing pelvic exenteration. While the technique is relatively simple, it can be very time-consuming and uses a significant portion of the patient's colon in its construction. Here a modification of the technique for construction of a continent ileocolic reservoir which results in a similar reservoir that uses less colon and requires less time to construct is presented. We also report results of the use of this technique in seven patients.

The effect of sartorius transposition on wound morbidity following inguinal-femoral lymphadenectomy.

In spite of efforts to reduce complications associated with inguinal-femoral lymphadenectomy (IFL), morbidity continues to be substantial. We sought to assess the efficacy of sartorius transposition (ST) in reducing groin wound complications following IFL, in patients with vulvar malignancy. The records of 101 patients with vulvar cancer undergoing IFL through separate incisions between March 1975 and December 1994 were examined. Sixty-two patients undergoing ST (group 1) were compared to 38 who did not (group 2). The groups were similar with respect to age, weight, tobacco/alcohol use, prior abdominal/vulvar surgery, prevalence of diabetes, hypertension, or peripheral vascular disease, and previous exposure to irradiation or chemotherapy. Additionally, there was no significant difference with respect to extent of disease, incidence of macro-/microscopic groin metastases, use of groin drains, and use of perioperative antibiotics or deep venous thrombosis prophylaxis. Groin wound complications were less frequent in patients undergoing ST (group 1). The incidence of groin cellulitis was 30% in group 1 compared with an incidence of 58% in group 2 (P = 0.011). Significant groin wound morbidity, defined as either wound breakdown or cellulitis, was seen less frequently in group 1 (41% vs 66%; P = 0.029). Employing a multivariate analysis, only patient weight < 150 lbs and performance of ST were established as independently associated with a reduction in groin morbidity following IFL (P = 0.0281 and P = 0.0075, respectively). In conclusion, despite waning enthusiasm for its performance, ST appeared to significantly reduce the incidence of wound morbidity after IFL. Our data confirmed that separate incisions, and improved perioperative antibiotics, have not eliminated the value inherent in this surgical modification. We suggest a prospective trial to further establish the benefit of sartorius transposition during IFL.

The safety and efficacy of extensive abdominal panniculectomy at the time of pelvic surgery.

Nine massively obese patients underwent excision of a large abdominal panniculus in conjunction with pelvic surgery. The most frequent indication for surgery was endometrial cancer. The charts of the patients were reviewed with careful attention to the outcome of the operation and the postoperative course. Comparison was made to previously reported data. The patients ranged in age from 48 to 72 years (mean 56). Weight range was 216 to 325 pounds (mean 261) and averaged more than twice ideal body weight. The weight of the resected abdominal wall was 3900 to 11,000 grams (mean 6247). Hospital stay ranged from 6 to 18 days (mean 8.2). Postoperative complications were chiefly those associated with the dead space created by the large resection without flap undermining (seromas in 2 and wound infections in 3). Four patients required prolonged wound drainage as outpatients. The average length of time to complete wound healing was 40.3 days (range 10 to 65). There were no dehiscences, pulmonary emboli, or operative mortalities. No patients required reoperation. Our study demonstrates that it is possible to safely combine plastic and gynecologic surgery without significantly increasing operative time, blood loss, postoperative complications, or hospital stay.