Pulsed low dose rate brachytherapy for uterine cervix carcinoma.

PURPOSE: To analyze the outcome and complication rates for patients treated with curative-intent pulsed low dose rate (PLDR) brachytherapy and external beam radiation therapy (EBRT) for uterine cervical carcinoma. METHODS AND MATERIALS: Fifty-two patients have been treated, of whom 6 were excluded from analysis due to limited follow-up. Six patients were stage Ib, 3 were IIa, 11 IIb, 3 IIIa, 14 IIIb, 1 IVa, and 9 were treated for local recurrences following primary surgery for stage Ib disease. Thirty-six patients had squamous cell carcinoma, 8 adenocarcinoma, 1 adenosquamous, and 1 carcinosarcoma. Thirty-one had a staging laparotomy prior to radiation therapy. Brachytherapy was interstitial in 18 patients, and intracavity in 28. The median EBRT central pelvis dose was 45 Gy in 25 fractions. Median total prescribed doses (EBRT plus PLDR) were 75.8 Gy to the implant volume with interstitial, and 84.1 Gy to the A points with intracavitary, at a median dose rate of 0.55 Gy per pulse per hour. Six patients had laparotomy-documented periaortic node involvement, and received EBRT to this site, 45 Gy in 25 fractions. Thirty patients received concomitant weekly cisplatin chemotherapy (40 mg/m2). RESULTS: With a median follow-up of 25 months (range 6 to 55 months) actuarial 4-year disease-free survival (DFS) rates are 66% for the entire group: stage Ib 100%, stage II 69%, stage III/IVa 68%, and 43% in patients treated for recurrences after surgery for initial stage Ib disease. Pelvic nodes contained tumor in 13 of the 31 patients (41.9%) who underwent laparotomy, as did periaortic nodes in 6 (19.4%). Patients with negative pelvic nodes had a 4-year actuarial DFS of 75% versus 59% with positive pelvic (and negative periaortic) nodes, and 50% with positive periaortic nodes. Using the RTOG late radiation morbidity scoring criteria, there were no grade V complications. Grade IV complications occurred in 2 patients (4.3%). One was a rectovaginal fistula and the other a vesicovaginal fistula, each occurring subsequent to a biopsy revealing benign tissue. One patient (2.2%) had a grade III complication (frequent hematuria), and 5 (10.9%) had grade II complications. CONCLUSIONS: PLDR brachytherapy is a safe and effective brachytherapy method in the treatment of cervix carcinoma. It combines the physics benefits of dose optimization and the radiobiologic advantages of low dose rate brachytherapy. It eliminates radiation exposure to staff and visitors as well as the need for a source inventory. Although further follow-up will be required, it appears to provide outcome which compares favorably to other methods of brachytherapy delivery, and results in a low rate of complications.

Carcinosarcoma of the fallopian tube.

A patient with Stage III fallopian tube carcinosarcoma treated with cisplatin, doxorubicin, and cyclophosphamide, surviving 31 months disease-free after diagnosis, is presented. Review of the literature revealed this is the 28th case report of malignant mixed Mullerian tumor of the fallopian tube, and fifth instance in which chemotherapy was used as a primary therapy. Modern chemotherapy appears to have improved survival.

Exfoliative dermatitis: presenting sign of fallopian tube carcinoma.

A woman presented with severe exfoliative dermatitis and a pelvic mass subsequently found to be fallopian tube carcinoma. After resection of the tumor and four courses of cisplatin, doxorubicin, and cyclophosphamide, the skin condition cleared.

Glassy cell carcinoma of the fallopian tube. A case report.

A 31-year-old woman, 10 weeks postpartum, presented with a right adnexal mass. The neoplasm was found to originate from the right fallopian tube and a right salpingoophorectomy was performed. Pathological examination found an adenosquamous carcinoma with features characteristic of a glassy cell carcinoma as described in the uterine cervix. The finding of this neoplasm in the fallopian tube suggests that it may be a tumor type common to the entire müllerian system.

Bladder perforation caused by cucumis sativus repaired per vagina.

A case of bladder perforation secondary to simulated intercourse with a cucumber is presented. Treatment by primary vaginal repair was successful.

Computed tomography in the pretreatment assessment of carcinoma of the cervix.

Fifty-nine patients with primary or recurrent carcinoma of the cervix were evaluated by computed tomography as part of their presurgical evaluation. The computed tomography staging results were compared with the surgical staging. Computed tomography staging was accurate in 71% (42 of 59), whereas clinical staging was accurate in 66% (39 of 59). In assessing paraaortic nodes by CT, there were 10 true-positive, 20 true-negative, 1 false-positive, and 2 false-negative results (sensitivity, 83%; specificity, 95%), for an overall accuracy of 91%. For pelvic nodes, there were 10 true-positive, 11 true-negative, 3 false-positive, and 6 false-negative results (sensitivity, 62.5% specificity, 78%), for an overall accuracy of 70%. Excretory urograms and barium enemas provided no information not obtained by computed tomography and are probably unnecessary if computed tomography is used as a routine staging examination. At present, computed tomography should not replace clinical assessment of extent of the disease. Its chief advantage over clinical staging is its ability to detect metastases beyond the true pelvis.

Isolation of a human papillomavirus from a patient with epidermodysplasia verruciformis: presence of related viral DNA genomes in human urogenital tumors.

The DNA genome of a human papillomavirus (HPV), tentatively designated HPV-EV, was molecularly cloned from hand to leg lesions of a patient with epidermodysplasia verruciformis, a chronic skin disease associated with a 30% risk of developing cancer. Using stringent hybridization conditions, we observed less than 5% homology between HPV-EV and the cloned genomes of HPV-1, HPV-4, HPV-5, and HPV-5a. HPV-EV DNA showed approximately 6% homology with HPV-2 and 36% homology with HPV-3. These data suggest that HPV-EV is partially related to HPV-3. Using 32P-labeled cloned HPV-EV as probe in Southern blot hybridization experiments, we detected HPV-EV-related DNA in the carcinoma in situ (Bowenoid lesion) of the vulva of the patient from which HPV-EV was isolated. HPV-EV-related DNA was detected in 2 of 10 vulva carcinomas and in 2 of 31 cervical carcinomas. Related DNA sequences were found in papillomas from each of two patients with condyloma acuminata (anogenital warts), which is of interest considering that condylomas have been reported to convert occasionally to carcinomas. The positive vulva DNAs were also probed with other cloned HPV DNAs: HPV-1, HPV-4, and HPV-5a-related sequences were not detected; HPV-3 and HPV-2 DNA probes detected strong and weak DNA bands, respectively, of the same size as found with HPV-EV. The HPV DNA sequences were present in the positive tumors mainly as free viral DNA molecules; no evidence for integration into cellular DNA was found. The emerging biological picture with papillomaviruses is that cells transformed by these viruses are maintained in a transformed state by free episomal genomes. Thus, our findings are consistent with the idea, but by no means establish, that HPVs play a role in human cancer by a similar mechanism.

Dysgerminoma of the ovary.

From 1938 to 1977, 21 patients with pure dysgerminoma were treated at Memorial and James Ewing Hospitals, now Memorial Sloan-Kettering Cancer Center. Twelve patients were considered to have their initial therapy begun or completed at our institution. Eleven (91.7%) of 12 patients were found free of disease from 2 to 38 years (median 6 years). Nine patients were referred with recurrent disease. Only 4 (45%) could be salvaged 2 to 21 years (median 9 years). Because of the lower survival rate in the treatment of recurrent disease in this series, it is difficult to advocate overly conservative therapy initially in all early lesions. The survival rate depends on the original size of the tumor, initial adequate staging and appropriate therapy based on the extent of disease. Recommendations for a treatment protocol are proposed.