Embryonal rhabdomyosarcoma: adjuvant and ex vivo assay-directed chemotherapy.

The aim of this retrospective study was to evaluate differences in treatment of embryonal rhabdomyosarcoma (RMS) of the uterus in 2 premenopausal women. We discuss adjuvant chemotherapy and use of ChemoFx Assay (Precision Therapeutics, Pittsburgh, PA) to guide choice of active chemotherapeutic agents. Two premenopausal patients were identified with a pathologic diagnosis of embryonal RMS of the uterus. Both met inclusion criteria for the study. A 21-year-old woman underwent a staging abdominal hysterectomy for a variant of embryonal RMS. Vincristine, actinomycin D, and cyclophosphamide were given adjunctively for a complete response. A 20-year-old woman underwent a diagnostic dilation and curettage revealing embryonal RMS. Initial treatment included an abdominal hysterectomy and nodal sampling. Presentation to a subsequent gynecologic oncologist 7 months later revealed recurrence. Carboplatin, doxorubicin, and paclitaxel provided a partial response. After a second surgical resection, ChemoFx Assay identified ifosfamide and mitomycin C as active agents and resulted in a complete response. Recommended treatment includes surgery and chemotherapy with possible radiation therapy if deemed necessary. The benefit of adding neoadjuvant or adjuvant chemotherapy and radiation therapy allows for a conservative surgical approach and improved survival. Choosing active chemotherapy agents can be aided by ChemoFx Assay. The chemotherapy most commonly used for treatment of embryonal RMS is a combination of vincristine, actinomycin D, and cyclophosphamide.

Secondary cervical cancer in a patient with chronic lymphocytic leukemia and recurrent chronic lymphocytic leukemia mimicking recurrent cervical dysplasia: a case report.

BACKGROUND: Patients with chronic lymphocytic leukemia (CLL) have up to a 3-fold risk of site-specific secondary cancers. The only exception is a lower incidence of cervical cancer in this population. CASE: A 70-year-old, white woman with stage IV CLL was diagnosed 2 years prior to presentation with stage Ia1 squamous cell carcinoma of the cervix. Following an abnormal Pap smear, a colposcopy and biopsies were performed. Initial pathologic impression of the cervical biopsies was high grade dysplasia. The final review was consistent with CLL without cervical dysplasia. CONCLUSION: Cervical cancer in patients with CLL is a rare occurrence. The pathologic changes on cervical epithelium caused by CLL can mimic dysplastic cellular changes. Expert pathologic review of cervical biopsies is warranted to distinguish between the diagnoses, thus altering management.

Response of an Obstetric Unit during the Coronavirus Disease of 2019 (COVID-19) Pandemic: Experiences from a Tertiary Care Center.

Objective To describe our experiences in preparing our obstetric unit in Westchester County, New York, during the COVID-19 (coronavirus disease of 2019) pandemic. We focus on describing our timeline, continuously evolving actions, observations, and challenges. Methods With guidance from the New York State Department of Health (NYSDOH), our institutional epidemiologist, and key multidisciplinary faculty members, we evaluated emerging national data as well as expert opinions to identify issues and challenges to create action plans. Results We created and modified policies for our patients presenting for obstetrical care on the labor and delivery unit to accommodate their unique needs during this pandemic. Conclusion The COVID-19 pandemic has posed many unique challenges. Balancing communication, risks of infection to providers, patient autonomy and rights, and resources for testing and personal protective equipment were among the valuable lessons learnt. We have shared our experiences and described our observations and challenges in Westchester County, New York.

Clinical trial participation is associated with improved outcome in women with ovarian cancer.

OBJECTIVES: To determine the effect of participation in clinical trials on survival of women with ovarian cancer. Disease-specific factors and demographics were also examined. METHODS: A total of 158 women were treated for ovarian cancer at a regional cancer center. All patients were offered treatment with surgery/chemotherapy and were screened at diagnosis for participation in clinical research. Progression-free and overall survival, as well as demographic- and treatment-related data, were recorded. RESULTS: Fifty-three participated in clinical trials and 105 did not. On-study versus off-study subjects were similar in age (64.1 vs 63.5 years), ethnicity (87% vs 85% white), performance status (100% 0-1 Gynecologic Oncology Group scale), and urban versus rural lifestyle (58% vs 55% urban). Stage of disease, histologic subtype, and type/amount of therapy were also similar. Kaplan-Meier analysis showed superior overall survival for on-study subjects (median, 46 vs 25 months, 95% confidence interval, 1.0299-2.1505 months, P = 0.0343). A trend toward improved progression-free survival approached significance for on-study subjects (median, 23 vs 9 months, 95% confidence interval, 0.9545-2.0022 months, P = 0.0866). CONCLUSIONS: Women with ovarian cancer who participate in clinical trials at this institution have improved survival compared with those who are treated with standard therapies. No other factors examined were associated with treatment completion or survival. Further, participation in clinical research does not vary by age, ethnicity, urban versus rural lifestyle, or cancer stage or histologic subtype. However, disclosure of this information to potential clinical trial participants may represent an ethical conflict and should be carefully considered in light of existing ethical guidelines for human subject research.

A rare malignant Brenner tumor of the ovary in a 77-year-old woman: a case report.

BACKGROUND: A malignant Brenner tumor is a rare form of invasive epithelial ovarian cancer and is extremely uncommon in women > 65 years of age. We present a case of an invasive Brenner tumor of the ovary in a woman greater than age 70. CASE: A 77-year-old woman presented with a rare, invasive Brenner tumor of the ovary. She was referred for evaluation of a complex pelvic mass and elevated serum CA-125. Treatment included complete surgical resection and staging procedure. Pathology revealed a malignant Brenner tumor. Immunohistochemical staining with cytokeratin 7 was positive, with cytokeratin 20 was negative, and was positive for uroplakin III and thrombomodulin. CONCLUSION: The histologic appearance of malignant Brenner tumor is similar to that of transitional cell cancer of the ovary and transitional epithelium of the urinary bladder. Immunohistochemical staining of malignant Brenner tumor often demonstrates positivity for uroplakin III, thrombomodulin and cytokeratin 7 and negativity to cytokeratin 20. The mainstay of treatment is surgical resection, but the exact regimen and benefit of adjuvant therapy remain unknown.

Contributions of stromal metalloproteinase-9 to angiogenesis and growth of human ovarian carcinoma in mice.

BACKGROUND: The expression level of several matrix metalloproteinases (MMPs), including MMP-2 and MMP-9, in ovarian cancer cells is directly associated with their invasive and metastatic potentials. MMP-9 is also expressed in stromal cells adjacent to the tumor. To investigate the contribution of MMP-9 expression in stromal cells to ovarian tumor growth, we examined angiogenesis and progressive growth of human ovarian cancer cells implanted into mice with and without the MMP-9 gene. METHODS: Human ovarian cancer cells SKOV3.ip1 and HEY-A8 were implanted into the peritoneal cavities of nude mice that lacked the gene for MMP-9 (MMP-9(-/-)) or were wild type for MMP-9 (MMP-9(+/+)) (10 mice of each genotype per cell line). Tumor incidence, tumor size, and volume of ascites fluid were recorded for each mouse at 30 and 45 days after HEY-A8 and SKOV3.ip1 cell injections, respectively. Blood vessel density and macrophage infiltration into the lesions were analyzed in excised tumors by immunohistochemistry and double immunofluorescence. Tumor growth was also studied in MMP-9(-/-) nude mice that had been reconstituted with spleen cells collected from either MMP-9(+/+) or MMP-9(-/-) nude mice. All statistical tests were two-sided. RESULTS: HEY-A8 cells expressed high levels of MMP-9, and SKOV3.ip1 cells expressed low levels. Nevertheless, tumor incidence and growth were statistically significantly lower in MMP-9(-/-) mice than in MMP-9(+/+) mice injected with cells from either line (for tumor size, P =.006 and.042 for HEY-A8 and SKOV3.ip1 cells, respectively). Compared with MMP-9(+/+) mice injected with human ovarian cancer cells, MMP-9(-/-) mice injected with human ovarian cancer cells displayed decreased microvessel density and decreased macrophage infiltration into the lesions. Compared with MMP-9(-/-) mice that received spleen cells (a rich source of macrophages) from MMP-9(-/-) mice, those that received spleen cells from MMP-9(+/+) mice before cancer cell injections displayed increased angiogenesis and tumorigenicity of the cancer cells. The growing tumors contained MMP-9-expressing macrophages. CONCLUSION: Host-derived MMP-9 expression, most likely in tumor-infiltrating macrophages, appears to play a critical role in angiogenesis and progressive growth of human ovarian tumors in mice.

Synergistic therapy of human ovarian carcinoma implanted orthotopically in nude mice by optimal biological dose of pegylated interferon alpha combined with paclitaxel.

The purpose of this study was to optimize the antitumor andantiangiogenic activities of pegylated IFN-alpha (PEG-IFN-alpha)alone or in combination with paclitaxel against SKOV3ip1 human ovarian cancer cells growing orthotopically in female nude mice. Seven days after the i.p. implantation of tumor cells, groups of mice (n = 10) were injected s.c. once per week (for 4 weeks) with different doses of PEG-IFN-alpha (3,500, 7,000, 35,000, and 350,000 units). PEG-IFN-alpha at 7,000 units significantly decreased tumor incidence and volume. At doses exceeding 7,000 units, PEG-IFN-alpha was less efficacious. In another set of studies conducted 7 days after the i.p. implantation of SKOV3ip1 cells, groups of mice (n = 10) received (once per week for 4 weeks) either s.c. administrations of PEG-IFN-alpha (7,000 units), i.p. injections of paclitaxel (100 microg/wk), or a combination of PEG-IFN-alpha and paclitaxel. The mice were killed 7 days after the last treatment, and tumor burden was assessed. Administration of PEG-IFN-alpha at the optimal biological dose (7,000 units) in combination with paclitaxel significantly decreased angiogenesis and progressive growth of human ovarian carcinoma cells in a synergistic fashion. The combination therapy produced the most significant inhibition in expression of the proangiogenic molecules basic fibroblast growth factor and matrix metalloproteinase-9. Decreased microvessel density, decreased proliferating cell nuclear antigen staining, and increased endothelial cell apoptosis also correlated with therapeutic success. Collectively, the data suggest that combining the optimal biological dose of PEG-IFN-alpha with paclitaxel may provide a novel and effective approach to the treatment of human ovarian carcinoma.

The roles and limitations of robotic surgery for obese endometrial cancer patients: a common challenge in gynecologic oncology.

In the United States, the epidemic of obesity is readily apparent in women diagnosed with endometrial cancer, the most common gynecologic malignancy. Overall, the benefits of minimally invasive surgery and its oncologic outcomes are similar among laparoscopy and robotic approaches. However, in stratifying obese patients by BMI, more data is needed on morbidly obese patients and their candidacy for robotic surgery along with the technical challenges of staging procedures. Cost analysis studies targeted specifically to the obese and morbidly obese patient is needed to further justify efforts at promoting robotic surgery in this patient population.

Routine cystoscopy after robotic gynecologic oncology surgery.

BACKGROUND AND OBJECTIVES: Our aim was to determine whether the use of routine cystoscopy increases lower urinary tract injury detection (bladder and/or ureter) after robotic surgery performed by gynecologic oncologists. METHODS: A retrospective chart review of patients who presented for robotic hysterectomy from 2009-2012 was performed at 2 separate academic medical centers, one that performed routine cystoscopy and one that did not. Statistical analysis was performed with t tests and χ2 tests. RESULTS: We identified 140 cases without cystoscopy and 109 cases with routine cystoscopy. There were no intraoperative or postoperative urinary injuries detected in either group. There were no significant differences in age and body mass index. In the non-cystoscopy group, a larger specimen size (P<.001), less blood loss (P=.013), and a longer mean operative time were observed (P<.0001). In the routine cystoscopy group, more lymphadenectomies were performed with hysterectomy (P=.007) and more patients underwent hysterectomy for ovarian cancer (P=.0192). There were no differences in surgical indications or secondary procedures including bilateral salpingo-oophorectomy, radical hysterectomy, ureterolysis, and pelvic organ prolapse-related procedures. The minimum follow-up period was 30 days in both groups. CONCLUSION: Routine use of cystoscopy did not appear to affect the detection rate of intraoperative lower urinary tract injury during robotic gynecologic surgery because this rate was zero in both groups. However, cystoscopy is relatively simple to perform and can be efficiently incorporated into robotic surgery to avoid the severe morbidity and possible litigation surrounding a urinary tract injury.

Grade 1 endometrioid endometrial carcinoma presenting with pelvic bone metastasis: a case report and review of the literature.

Most grade 1 endometrioid endometrial cancers are confined to the uterus at the time of diagnosis and confer a good prognosis. Rarely will a grade 1 endometrioid endometrial carcinoma present with distant metastasis, especially to the bone. We present the case of a 56-year-old woman with postmenopausal bleeding and right hip pain due to metastatic grade 1 endometrioid uterine cancer invading into the right ischium. We discuss treatment options as well as provide a review of prior published reports on bony metastasis in grade 1 endometrioid endometrial cancers. To date, this case is one of 10 others which demonstrates that even a well-differentiated, low-grade endometrioid endometrial carcinoma can progress in a highly aggressive manner.

Two cases of post-coital vaginal cuff dehiscence with small bowel evisceration after robotic-assisted laparoscopic hysterectomy.

INTRODUCTION: Vaginal cuff dehiscence following robotic surgery is uncommon. Published reports of vaginal cuff dehiscence following robotic surgery are increasing, but the true incidence is unknown. PRESENTATION OF CASE: Case 1. A 45 year old female had sexual intercourse and presented with a vaginal cuff dehiscence complicated by small bowel evisceration 4 months after RA-TLH. Case 2. A 44 year old female had sexual intercourse and presented with a vaginal cuff dehiscence with small bowel evisceration 6 weeks after RA-TLH. DISCUSSION: We discuss the rate of vaginal cuff dehiscence by mode of hysterectomy, surgical and non-surgical risk factors that may contribute to vaginal cuff dehiscence, and proposed preventative methods at the time of RA-TLH to reduce this complication. CONCLUSION: Vaginal cuff dehiscence with associated evisceration of intraabdominal contents is a potentially severe complication of hysterectomy. We recommend counseling patients who undergo RA-TLH to abstain from vaginal intercourse for a minimum of 8-12 weeks.

Abdominal wall port site metastasis after robotically staged endometrial carcinoma: A case report.

INTRODUCTION: The incidence of port-site metastasis following robotic-assisted laparoscopic hysterectomy is unknown. PRESENTATION OF CASE: We present a case of a 78-year-old female diagnosed with an incidental grade 3 endometrial adenocarcinoma on a final hysterectomy specimen. She subsequently underwent a robotic staging surgery with a gynecologic oncologist where nodal pathology was found to be negative; her final stage was 1B. One year following diagnosis, she developed a recurrence on her abdominal wall at the former port-sites with concomitant vaginal cuff recurrence. DISCUSSION: We hypothesize possible modes of metastasis and present limited published data to date on port site metastasis following robotic hysterectomy for endometrial cancer. CONCLUSION: This is the second reported case of port-site metastasis following robotic surgery for endometrial cancer.

Rare large cell neuroendocrine tumor of the endometrium: A case report and review of the literature.

INTRODUCTION: Large cell neuroendocrine carcinoma (LCNEC) of the endometrium is a rare malignancy with an aggressive course. Although data is limited to case reports, the prognosis appears to be poor, similar to other type II uterine cancers. A total of 12 cases of LCNEC of the uterus have been published to date. PRESENTATION OF CASE: A 71 year-old woman presented with postmenopausal vaginal bleeding. Endometrial biopsy was non-diagnostic for LCNEC. She underwent surgical debulking and staging of a 22cm endometrial tumor with omental metastasis and positive lymph nodes. Her final FIGO stage was IVB. DISCUSSION: We summarize all prior case reports of LCNEC of the endometrium and discuss the definition, presentation, imaging and surgical management. The pathology with immunohistochemical review, adjuvant therapy and prognosis of LCNEC of the endometrium are also reviewed. CONCLUSION: Pathologic findings and immunohistochemistry are essential in making a diagnosis of LCNEC of the endometrium. Primary debulking and surgical staging is typically performed, but if a diagnosis of LCNEC can be made preoperatively with immunohistochemistry, surgeons should consider neoadjuvant chemotherapy due to its high grade histology and aggressive course. Otherwise adjuvant chemotherapy is usually given. Even with early stage disease, the prognosis seems poor. Due to the rarity of this aggressive malignancy, more data is needed to establish incidence.

Perspective for prophylaxis and treatment of cervical cancer: an immunological approach.

As the second most common cause of cancer-related death in women, human papilloma virus (HPV) vaccines have been a major step in decreasing the morbidity and mortality associated with cervical cancer. An estimated 490,000 women are diagnosed with cervical cancer each year. Increasing knowledge of the HPV role in the etiology of cervical cancer has led to the development and introduction of HPV-based vaccines for active immunotherapy of cervical cancer. Immunotherapies directed at preventing HPV-persistent infections. These vaccines are already accessible for prophylaxis and in the near future, they will be available for the treatment of preexisting HPV-related neoplastic lesions.