Preoperative predictors of positive margins after loop electrosurgical excisional procedure-Cone.

OBJECTIVE: A LEEP-Cone may not be necessary for all patients with traditional cone indications. This study defines populations where a single pass technique with the LEEP is appropriate. METHODS: We retrospectively reviewed patients undergoing LEEP-Cone procedures performed at the University of Oklahoma Health Science Center from February of 1994 to July of 2002. Patients include those for LEEP-Cone with traditional excisional indications and those who underwent LEEP-Cone at the operating physician's discretion. Statistical analysis was used to compare preoperative factors with the resultant pathologic results. RESULTS: A total of 248 women underwent LEEP-Cone. 50.0% (33/66) of the patients with positive margins on the first pass had dysplasia or worse (CIN I-III or CA) in the second pass (top hat), compared to 6.6% (12/182) of the patients with a negative first pass (P < 0.0001). Univariate analysis found CIN III on histology and parity to be predictive of dysplasia in the top hat and two-step discrepancy to predict absence of dysplasia. On multivariate analysis, two-step discrepancy and parity remained predictive. Age >35 was the greatest percentile predictor of dysplasia in the top hat, and 91.5% of women <21 had normal top hat pathology. CONCLUSION: The retrospective data reported regarding LEEP-Cones reveal increased parity to predict dysplasia in the top hat and two-step discrepancy as a poor predictor of dysplasia in the top hat. Women under 21 years of age should have a single pass LEEP technique. The "top hat" is more appropriate as parity and age increase.

Management of atypical and low-grade cervical cytology.

The finding of atypical and low-grade cervical cytology on routine Papanicolaou test is considered problematic for gynecologists and pathologists. The interpretation and management of these cases can be difficult when Papanicolaou test results fall into the Bethesda 2001 categories of atypical squamous cells, atypical squamous cells--cannot rule out high-grade, atypical glandular cells, or low-grade squamous intraepithelial lesion. Although liquid-based Papanicolaou tests may have resulted in some improvement in detection, a large amount of variability in cytologic interpretations continues to exist. The recent approval of concurrent use of high-risk human papillomavirus DNA testing with cytology in the screening of women for cervical neoplasia adds a new dilemma to patient management: What should we do with women who are positive for high-risk human papillomavirus DNA but have negative cervical cytologic results?

Gemcitabine and cisplatin chemotherapy is an active combination in the treatment of platinum-resistant ovarian and peritoneal carcinoma.

The treatment of recurrent ovarian cancer with the combination of gemcitabine and cisplatin chemotherapy has recently been shown to be an active regimen. But the majority of positive responses have been observed in patients considered either platinum-sensitive or who have had extended platinum-free intervals. The purpose of our study was to review our experience with this regimen in women with platinum-resistant ovarian and peritoneal carcinoma with more recent exposure to platinum. We studied twenty-two patients who had relapsed within six months of their most recent platinum-based regimen and were treated with gemcitabine (450-600 mg/m(2)) and cisplatin (30 mg/m(2)) on days 1 and 8 of a 21-day cycle. The overall response rate was 64% (95% C.I. 42-85%) with seven (32%) complete and seven (32%) partial responses. The median progression-free interval was 6.7 months for responding patients and 3.9 months for the entire study group. Median survival for responders was 15.8 months compared to 8.8 months for non-responders. Overall survival was 11.4 months. Grade 3 or 4 toxicity was encountered in 59% of treatments. We conclude from this limited review that the combination of gemcitabine and cisplatin chemotherapy is an active regimen in platinum-resistant ovarian and peritoneal carcinoma and warrants consideration in the management of patients with recurrent disease.

Uterine papillary serous carcinoma: comparisons of outcomes in surgical Stage I patients with and without adjuvant therapy.

OBJECTIVE: Our aim was to determine the outcomes of Stage I uterine papillary serous carcinoma (UPSC) patients with and without adjuvant therapy after comprehensive surgical staging. METHODS: Patients with FIGO Stage I UPSC diagnosed from 1987 to 2000 were identified from tumor registry databases at four institutions. A retrospective chart review identified 60 women who underwent comprehensive surgical staging, including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic/para-aortic lymphadenectomy, and peritoneal cytology. Fisher's exact, chi(2), and log-rank tests were used for the statistical analyses. RESULTS: Of the 60 Stage I patients, 40 (66%) patients received no adjuvant therapy, 12 (20%) received adjuvant radiation therapy (XRT), 7 (12%) received adjuvant chemotherapy (CHM), and 1 (2%) received both XRT and CHM. There were seven recurrences in the observation group versus two recurrences in the XRT group (17% vs 16%, P = 0.9). No recurrences or deaths were observed in the CHM group. The mean disease-free survival rates for the observation and the XRT groups were 31 and 41 months, respectively. The mean overall survival rates for the observation and XRT groups were 39 and 40 months, respectively. The 5-year disease-free survival rates for the observation and XRT groups were 65 and 60%, respectively; the 5-year overall survival rates for observation and XRT groups were 66 and 59%. There was no statistical difference in overall survival among the three groups. CONCLUSION: In this largest reported series of surgical Stage I UPSC patients, recurrence rates were lower than those published in previous studies, suggesting a potential benefit of comprehensive surgical staging in these patients. The risk of recurrence and the mean overall survival were similar between surgical Stage I UPSC patients who were managed conservatively and those treated with adjuvant radiation therapy. These data question the benefit of radiation therapy in UPSC patients with disease confined to the uterus. Finally, given the absence of recurrences and disease-related deaths for adjuvant chemotherapy in these patients, a Phase II/III trial evaluating adjuvant chemotherapy in surgical Stage I UPSC patients should be considered.