Human papillomavirus genotypes in Pacific Islander cervical cancer patients.

OBJECTIVE: The role of human papillomavirus (HPV) in the development of invasive cervical cancers is widely known. Few HPV studies have targeted geographically isolated regions. The objective of this study was to determine the HPV genotypes in cervical cancer patients from the Pacific Islands referred to Tripler Army Medical Center (TAMC). METHODS: All cases of invasive cervical cancer treated at TAMC through the Pacific Island Health Care Project between January 2004 and October 2014 were identified through a review of pathology specimens. DNA was extracted from paraffin-embedded tissue blocks. PCR was performed using PLEX-ID plates to isolate and amplify HPV-specific DNA. Mass spectrometry was subsequently performed to identify specific HPV genotypes. RESULTS: Thirty-five patients had their pathology specimens analyzed. Ten patients had localized disease (Stage 1); 21 had regional disease (Stages 2 and 3); and 4 had distant disease (Stage 4). Thirty-three squamous cell carcinomas and 3 adenocarcinomas were identified. The most common HPV subtypes found were 16 (6, 24%), 45 (6, 24%), and 52 (6, 24%). Other HPV subtypes isolated included 18 (1, 4%), 33 (3, 12%), 39 (2, 8%), 54 (1, 4%), and 67 (1, 4%). In 10 samples, HPV was not isolated. CONCLUSION: Pacific Islanders referred to TAMC present with a disproportionally higher rate of regional and advanced disease. Significantly, only 28% of invasive cervical cancers in the Pacific Island population sampled could have been potentially be prevented using the available quadrivalent vaccine targeting HPV 16/18; however, 88% could be covered by the recently licensed nonavalent vaccine.

Primary appendiceal cancer: gynecologic manifestations and treatment options.

OBJECTIVE: To determine the presenting symptoms, gynecologic manifestations, and optimal intraoperative management of women with primary appendiceal cancer. METHODS: A multi-institutional investigation was performed to identify female patients with primary appendiceal cancer who were treated from 1990 to present. RESULTS: Forty-eight women with primary appendiceal cancer were identified from the tumor registries of participating institutions. The most common symptoms were abdominal pain (40%) and bloating (23%), but only 8% experienced rectal bleeding. Serum CEA was elevated (>2.5 U/ml) in 67% of patients, and serum Ca-125 was elevated (>35 U/ml) in 50% of patients. Thirty-one patients (65%) presented with a right adnexal or right lower quadrant mass and were operated on initially by a gynecologic oncologist. Ovarian involvement by metastatic appendiceal cancer was documented in 18 patients (38%). All of these patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and staging, but only 8 had a right hemicolectomy at the time of initial surgery. Forty-one patients (85%) presented with advanced stage appendiceal cancer (Stage III or IV) and 19 patients (46%) received postoperative chemotherapy, most commonly with a combination of 5-FU/Leukovorin. Following surgery, 22 patients (46%) experienced disease progression or recurrence, and 14 have died of disease. The most common sites of recurrence were abdominal or pelvic peritoneum (18), colon (2), and ovary (2). Patient survival was 70% at 2 years, and 60% at 5 years. CONCLUSION: Women with primary appendiceal cancer frequently present with ovarian metastases, and initial surgical intervention is often performed by a gynecologic oncologist. All patients with mucinous epithelial ovarian cancer should undergo appendectomy at the time of surgical staging. The appendix should be examined intraoperatively, and if appendiceal carcinoma is identified, a right hemicolectomy and appropriate surgical staging should be considered.

The efficacy of adjuvant platinum-based chemotherapy in Stage I uterine papillary serous carcinoma (UPSC).

OBJECTIVE: To determine the efficacy of adjuvant platinum-based chemotherapy in Stage I uterine papillary serous carcinoma (UPSC). METHODS: A retrospective multi-institutional investigation was performed to identify surgically staged patients with Stage I UPSC who were (1) treated after surgery with 3-6 courses of platinum-based chemotherapy without radiation from 1990-2003, and (2) followed for a minimum of 12 months, or until recurrence. RESULTS: Six patients (IA-2, IB-3, IC-1) were treated with carboplatin (AUC 6) or cisplatin (50 mg/m2) alone. One patient recurred to the vagina, was treated with chemo-radiation, and is alive and well at 122 months. One patient recurred to the lung, liver, and brain, and died of disease at 24 months. The remaining 4 patients are alive with no evidence of disease 15-124 months (mean 62 months) after treatment. Two patients (IB-1, IC-1) were treated with cisplatin (50 mg/m2) and cyclophosphamide (1000 mg/m2), and both are alive and well with no evidence of disease 75 and 168 months after treatment. Twenty-one patients (IA-5, IB-13, IC-3) were treated with a combination of carboplatin (AUC 6) and paclitaxel (135 mg/m2-175 mg/m2). One patient recurred to the vagina after 3 cycles of carboplatin/paclitaxel, and was treated with chemo-radiation. She is now without evidence of disease 10 months after treatment. At present, all 21 patients with Stage I UPSC treated following surgical staging with carboplatin/paclitaxel chemotherapy are alive and well with no evidence of disease 10-138 months (mean 41 months) after treatment. CONCLUSION: Combination carboplatin/paclitaxel chemotherapy following surgery is effective in the treatment of Stage I UPSC.

Labor epidural analgesia and intrapartum maternal hyperthermia.

OBJECTIVE: To determine if women receiving continuous epidural analgesia are more likely to develop intrapartum fever and related neonatal effects. METHODS: We conducted a retrospective cohort analysis of nulliparous women with term gestations in spontaneous labor delivered during a 12-month period immediately before the availability of on-demand labor epidural analgesia (Before group) and a similar group of nulliparas delivered after labor epidural analgesia was available on request (After group). RESULTS: The frequency of epidural increased from 1% before the availability of on-request epidural analgesia to 83% after epidural analgesia was available on request. A maximal temperature of at least 100.4F was detected in three of 498 (0.6%) women in the Before group, and in 63 of 572 women (11.0%) in the After group (relative risk [RR] = 18.3, 95% confidence interval [CI] 5.8, 57.8, P <.01). Logistic regression analysis demonstrated that on-request labor epidural analgesia was associated with an intrapartum temperature of at least 99.5F (RR = 3.0, 95% CI 2.3, 3.6, P <.001) and intrapartum temperature of at least 100.4F (RR = 20.2, 95% CI 7.0, 86.0, P <.001). There were statistically significant increases in the proportion of newborns who had complete blood counts (24% versus 13.5%, RR = 1.5, 95% CI 1.3, 1.8, P <.01) and blood cultures (30.7% versus 8.6%, RR = 1.7, 95% CI 1.2, 2.4, P <.05) in the After period compared with the Before group; however, there was no statistically significant difference in the proportion of infants who received antibiotic therapy for presumed sepsis between the After and Before periods (5.8% versus 4.6%, RR = 1.15, 95% CI 0.8, 1.6, P =.38). No infants in either group had culture-proven sepsis. CONCLUSION: The use of labor epidural analgesia is associated with a clinically significant increase in the incidence of intrapartum fever.