[A woman with mohawks on the vaginal wall]. / Een vrouw met hanenkammen op de vaginawand.

A 27-year-old female was seen with exophytic protrusions on the vaginal wall. Biopsy showed a squamous papilloma. This benign tumour is an expression of a non-oncogenic human papillomavirus infection. Although treatment is not necessary, screening for sexual transmitted diseases is advised.

[Morbid obesity: a risk factor for obstetric complications]. / Morbide adipositas: risicofactor voor obstetrische complicaties.

In a primipara, 28 years of age and with a BMI of 44 kg/m2, a Zavanelli manoeuvre was performed. Due to uterine atony she had to undergo a hysterectomy. A multipara, 39 years of age and with a BMI of 66 kg/m2, experienced that her weight exceeded the limits of the beds and that local anaesthesia was hard to perform; she suffered from a lesion of the lumbosacral plexus caused by a shoulder dystocia. In the end, both mothers and their babies could go home in a moderate condition. Obesity is becoming more prevalent and brings with it an increase in obstetric risks. During pregnancy and delivery, morbidly obese patients should be monitored by a gynaecologist. Special interest should focus on screening for (gestational) diabetes, hypertension and foetal growth. Ultrasound may detect congenital malformations early; however, the sensitivity of ultrasound is lower in morbidly obese patients. When macrosomia is expected, a clear plan should be made regarding the mode of delivery. It is useful to make a treatment protocol for morbidly obese patients.

Weekly cisplatin and daily oral etoposide is highly effective in platinum pretreated ovarian cancer.

We investigated the potential of weekly cisplatin and daily oral etoposide followed by oral etoposide maintenance therapy in patients with platinum-refractory ovarium cancer. One hundred and seven patients were entered on the study, 98 patients completed the induction therapy consisting of cisplatin at either 50 or 70 mg m(-2) weekly for six administrations plus oral etoposide at a dose of 50 mg daily. Of these 98 patients, 38 had a platinum treatment-free interval of more than 12 months, 32 had an interval between 4 and 12 months, and 28 had progressed during or within 4 months after last platinum therapy. We assessed response rates and time to progression, and also response duration and survival. Analyses were done on the 98 evaluable patients. All 107 patients were considered evaluable for toxicity. Of the 38 patients with a treatment-free interval of more than 12 months, 92% responded, with 63% complete responses. The median progression-free survival in these patients was 14 months, and the median survival was 26 months. Of the 32 patients with an interval of 4-12 months, 91% responded, with 31% complete responses, a median progression-free interval of 8 and a median overall survival of 16 months. Of the 28 patients with platinum-refractory disease, 46% as yet responded, with 29% complete responses, median progression-free interval of 5 and an overall survival of 13 months. Haematologic and non-haematologic, particularly renal toxicity and neurotoxicity, were notably mild. We conclude that this intensive regimen of weekly cisplatin plus daily etoposide is highly effective and well tolerated in patients with ovarian cancer relapsing after conventional platinum-based combination chemotherapy, including patients who have progressed during or within 4 months after platinum treatment.

Metastasectomy, a feasible treatment in selected cases with gynecologic malignancy.

We present the course of six gynecological patients who underwent surgical intervention because of a solitary metastasis. After a considerable follow-up period five patients are alive without evidence of disease and with a good quality of life. Metastasectomy should play a role in the management of gynecologic malignancies.

Lymphedema and lymphocysts following lymphadenectomy may be prevented by omentoplasty: A pilot study.

OBJECTIVES: Pelvic lymph node dissection as part of the staging surgery for cervical carcinoma interrupts the afferent lymphatics, so the lymph drains retroperitoneally. New surgical techniques designed to leave the peritoneum open after the retroperitoneal dissection, in particular the application of a pedicled omentoplasty along the dissection route, have been advocated to prevent the formation of lymphocysts and lymphedema. We investigated the possible benefit of pedicled omentoplasty in preventing lymphocysts and lymphedema following pelvic lymph node dissection. METHODS: In this pilot study with historical controls we compared the formation of lymphocysts and lymphedema following two different surgical techniques for pelvic node dissection: group I (historical controls), in which the dorsal peritoneum was left open, and group II, in which the dorsal peritoneum was left open with application of a pedicled omentoplasty. In these two groups of gynecologic patients, we compared the lymph flow patterns and the occurrence of lymphedema following systemic pelvic lymphadenectomy. The two groups were of comparable clinical status and consisted of 12 (group I) and 10 (group II) patients. Lymphocysts, if any, were detected by CT scan, the lymph flow patterns were visualized by dynamic lymphscintography, and lymphedema was visualized by physical examination and magnetic resonance imaging of the groin and the upper leg. RESULTS: In both groups a distinct intraperitoneal absorption of the lymph fluid was observed. Pedicled omentoplasty seemed to facilitate the absorption or transport of lymph fluid, resulting in less lymphedema in the upper leg. CONCLUSION: It appeared that leaving the dorsal peritoneum open to give the lymph stream the opportunity to pour into the abdominal cavity is important in preventing lymphocysts and lymphedema. The dynamic lymphscintigraphy described in this paper showed that the intraabdominal lymph flow is absorbed by the peritoneum and even more quickly by the pedicled omentum.

Three-dimensional treatment planning for postoperative radiotherapy in patients with node-positive cervical cancer. Comparison between a conventional and a conformal technique.

PURPOSE: Reduction of irradiated small bowel volume, using a conformal three-dimensional treatment planning technique in postoperative radiotherapy of cervical cancer patients. PATIENTS AND METHODS: Large gynecological treatment fields including the para-aortic nodes were analyzed in 15 patients. A conventional treatment plan with anterior and posterior (AP-PA) parallel opposed fields and a 3D 4-field conformal radiotherapy plan with a central blocking of small bowel were compared for each patient. Dose-volume histograms and dose parameters were established. Because of the tolerance constraints of the small bowel, the cumulative dose applied to the target was 48.6 Gy. RESULTS: The mean Tumor Control Probability (TCP) values for both the conventional and the conformal technique were 0.60 and 0.61, respectively, with ranges of 0.56 to 0.67 and 0.57 to 0.66, respectively. The mean volume receiving 95% or more of the prescribed dose (V95) of the small bowel was 47.6% (32.5 to 66.3%) in the AP-PA technique and 14.9% (7.0 to 22.5%) in the conformal technique (p < 0.001), indicating a significant reduction in irradiated volume of small bowel in the higher dose range. The mean Normal Tissue Complication Probability (NTCP) decreased from 0.11 to 0.03 with the conformal plan. In patients who received a pedicled omentoplasty during surgery, the mean V95 for small bowel could be reduced to 8.5% (7.0 to 9.9%). The mean median dose to the kidneys was only slightly elevated in the conformal treatment. Especially the mean dose to the right kidney in conventional vs conformal treatment was 3.3 vs 7.9 Gy. The mean near-minimum dose (D95) to the rectosigmoid decreased from 48.4 to 30.1 Gy in the conformal plan compared to the conventional plan. CONCLUSION: The small bowel dose can be significantly reduced with 3D treatment planning, particularly if a pedicled omentoplasty is performed. This allows dose escalation to the tumor region without unacceptable toxicity for the small bowel.

A phase I/II study of combined weekly systemic cisplatin and locoregional hyperthermia in patients with previously irradiated recurrent carcinoma of the uterine cervix.

We investigated the feasibility and the anti-tumour activity of weekly cisplatin and the simultaneous application of local hyperthermia in patients with a pelvic recurrence of cervical cancer in previously irradiated area. Dose levels of cisplatin 60 mg m(-2), 70 mg m(-2) and 80 mg m(-2) were studied. Treatment objective of hyperthermia was the achievement of a tumour temperature of > or = 42 degrees for 60 min, during cisplatin administration. The protocol advised six weekly cycles of combined treatment. Nineteen patients, median age 47 years (range 26-71), were treated. A total of 89 cycles of combined treatment were administered. Even at the highest dose level of cisplatin, 80 mg m(-2) weekly, no dose-limiting toxicity was observed. Leucocytopenia at scheduled retreatment resulted in 1 or 2 weeks postponement in five cases. Neurotoxicity and renal toxicity were mild or absent. Maximum tumour temperatures achieved ranged 39.7-43.6 degrees C, mean 41.6+/-0.7 degrees C. All 19 patients were evaluable for response. One patient achieved a complete response that lasted 20 months, and nine patients achieved a partial response for a median duration of 6 months (range 4-50+ months), for an overall response rate of 53%. One patient subsequently underwent salvage surgery and currently remains free of disease at 4 years. We found that this combined hyperthermia-dose-intensive cisplatin regimen was well-tolerated. The true impact of the combination of cisplatin and locoregional hyperthermia can only be answered in a randomized study. Nonetheless, based on existing data on the poor efficacy of cisplatin in pelvic recurrent cervical cancer, we believe that the combined modality approach of weekly hyperthermia plus dose-intensive cisplatin is an attractive regimen, particularly if subsequent salvage surgery is available.

High tissue factor concentration in the omentum, a possible cause of its hemostatic properties.

The hemostatic properties of the pedicled omentoplasty turned out to be helpful in difficult hemorrhages in extensive surgery. As suggested by others, a high concentration of tissue factor (TF) in the omentum could be responsible for this favourable property. The authors investigated the nature of that property in 11 patients who underwent laparotomy. In omentum and striated muscle (controls) the TF-concentrations in both tissues were estimated by the ELISA method. A significant difference between TF-concentration in omentum and striated muscle could be demonstrated.

The omentoplasty: a neglected ally in gynecologic surgery.

Although the omentum is extensively used in general, reconstructive and thoracic surgery as a pedicled omentoplasty, little information exists about the utility of such a procedure in general and radical gynecologic surgery. In this paper we review the properties of the omentum which may be useful in gynecologic surgery. The omentum is highly vasculated and rich in thromboplastin, an excellent property for treating difficult to handle abdominal or pelvic abscesses and for inducing hemostasis. Furthermore, it appears that the omentum has a trophical effect on the surrounding tissue, making it very useful in reconstruction procedures. Moreover, elevating the small intestines out of the true pelvis paves the way for high dose (brachy)radiotherapy with less radiation enteritis. The technique of the pedicled omentoplasty is straightforward and takes 20-30 min extra operating time. We use pedicled omentoplasty for covering large operating fields instead of reperitonealization, to prevent radiation enteritis, as a matrix for grafting, to treat serious intraperitoneal infections and to facilitate hemostasis. Our experience of 48 omentoplasty procedures in gynecology is described.

The pedicled omentoplasty, a simple and effective surgical technique to acquire a safe pelvic radiation field; theoretical and practical aspects.

A substantial number of patients need radiotherapy after surgery for pelvic malignancy. Approximately 15% of them will experience radiation enteritis. After omentoplasty, reduction of irradiated bowel volume may be obtained. We evaluated the pedicled omentoplasty during gynaecologic surgery as a technique to improve safe irradiation of the pelvic region.

Results of curettage for postmenopausal vaginal bleeding in women treated with tamoxifen and megestrol acetate for progressive metastatic breast carcinoma.

Tamoxifen and megestrol acetate are used as a hormonal treatment for metastatic breast carcinoma. It is suggested that the use of tamoxifen may induce endometrial cancer. In this article we describe nine patients under hormonal treatment for metastatic breast cancer with, firstly, tamoxifen and, later, megestrol acetate. These nine patients all had symptoms of postmenopausal vaginal blood loss during therapy with megestrol acetate, an indication to perform a diagnostic dilatation and curettage. By histopathological examination the curettings showed a decidualized stroma with an infiltration of lymphocytes, some plasma cells and many eosinophils. In none of the patients was atypical hyperplasia or malignancy found. The dilatation and curettage had also a therapeutic effect, since only one of the patients still had complaints, while the other eight did not complain of postmenopausal bleeding again. We review the literature and discuss the value of a diagnostic dilatation and curettage.

Phase II study of prolonged oral etoposide in patients with ovarian cancer refractory to or relapsing within 12 months after platinum-containing chemotherapy.

PATIENTS AND METHODS: Twenty-eight patients with ovarian cancer refractory to or relapsing within 12 months after cisplatin-containing chemotherapy were treated with etoposide 50 mg/m2 daily for 21 days, followed by a 7-day break. RESULTS: Of 25 evaluable patients, 4 achieved partial responses (16%, 95% confidence interval 5%-36%) of 4, 4, 7, and 10 months' duration. The platinum treatment-free intervals for these patients were 2, 9, 7, and 10 months, respectively. Etoposide in this schedule was generally well tolerated, with myelosuppression as the major toxicity, resulting in a median dose intensity over all cycles of 83% (range 47%-100%). CONCLUSIONS: Prolonged oral etoposide is moderately active both in relapsed and platinum-refractory ovarian cancer, and a schedule of 50 mg/m2 days 1-21, every 4 weeks is fairly well tolerated in this usually heavily pretreated and elderly patient population.

Ovarian cysts, cytology and histology: a conflicting story.

Ovarian cysts from 27 selected patients were examined cytologically as well as histologically. The aspirates were obtained by means of ultrasound or laparoscopy. Cytological examination in 17 of the cases did not show malignancy, but histological examination demonstrated malignancy in 5 of these patients. The fluid of the other 10 cysts indicated malignancy, which was confirmed histologically in only 4 cases. From this study we conclude that cytological examination has little to offer in diagnosing the true nature of ovarian cysts.