Microinvasive carcinoma of the cervix. Analysis of prognostic factors.

INTRODUCTION: Superficially invasive neoplasias of the uterine cervix are a matter of controversy in terms of their definition, prognostic factors and selection of treatment to minimize the risk of recurrences. We reviewed our treatment to determine whether any factors affect this risk. PATIENTS AND METHODS: The present study was conducted on 59 patients seen at our service, 22 of them with early stromal invasion (IA1) and 37 with microinvasive carcinoma (IA2) according to FIGO criteria (1995). Ten patients were submitted to conization as definitive treatment, although for three of them treatment was complemented with Wertheim-Meigs surgery due to recurrence in the remaining cervix. The other 49 patients were submitted to total abdominal hysterectomy. RESULTS: Forty-four patients underwent diagnostic or therapeutic conization, and 14 of them presented involvement of the endocervical margin. Seven patients presented recurrence with involvement of the endocervical margin in five. The age of recurrence ranged from 40 to 70 years, with a mean of 52.3 years, as opposed to a general mean of 42.3 (p<0.05). Angiolymphatic invasion was positively correlated to recurrence and death (p<0.01) as well as depth of invasion. CONCLUSIONS: We conclude that the presence of a cone with an involved endocervical margin represents a high risk of recurrence and that this condition occurs in older patients who are prone to present more extensive lesions. Thus, age should be regarded as an important risk factor. Angiolymphatic invasion and depth of invasion have a poor prognosis in terms of recurrence and death.

Chemotherapy in the treatment of locally advanced cervical cancer and pregnancy.

BACKGROUND: Carcinoma of the cervix is the most common malignant tumor associated with pregnancy. The initial stages and premalignant lesions apparently present the same prognosis in pregnant and nonpregnant women; however, there are limited data regarding outcome for locally advanced cervical cancer in pregnancy. CASE: A 26-year-old woman, gravida 4, para 3, at 14 weeks and 4 days' gestation, was diagnosed with a FIGO stage IIB squamous cell carcinoma of the cervix, treated by primary chemotherapy with cisplatin and bleomycin, until pregnancy resolution at 38 weeks. The newborn infant is currently 3 years old and presents no evidence of abnormalities in neuropsychomotor development. CONCLUSION: The present case demonstrates that chemotherapy was harmless for the child up to the present time. However, a longer follow-up is needed to determine the safe outcome of this child.

Lymphocyte subpopulations in patients with advanced breast cancer submitted to neoadjuvant chemotherapy.

AIMS AND BACKGROUND: There is an enhanced immune response in patients with breast cancer after the use of chemotherapy. The objective of this study was therefore to investigate alterations in the number of peripheral lymphocytes in patients with breast cancer after neoadjuvant chemotherapy (NC) and the relationship with prognosis. METHODS: Thirty women were analyzed. Their UICC staging was IIb (only T3N0 included) and III (N3 not included). Sample analysis was performed using flow cytometry before the first cycle and 18 to 21 days after the last cycle of NC. The lymphocyte subsets studied were: T (CD3, CD4, CD8), B (CD19, CD23), natural killer (NK) (CD56, CD16), and interleukin-2 (CD25). CD3, CD56, CD8, and CD16 lymphocytes were analyzed with double marking. After x = 3.8 +/- 1.3 cycles of 5-fluorouracil, epirubicin and cyclophosphamide (FEC), 16 patients showed a complete or partial response (group 1). After three cycles 14 showed no response or tumor progression (group 2). A control group of healthy women was used for pretreatment analysis. RESULTS: Before NC there was a significant increase in B lymphocytes and NK cells in comparison to the control group. After NC there was a significant percentage increase in CD3, CD4, CD8, CD25 and CD3+CD56+ cells and a decrease in CD19, CD23, CD56, CD16 and CD16+CD8+ cells. There was a significant fall in the absolute number of CD4, CD19, CD23, CD56, CD16 and CD16+CD8+ lymphocytes and an increase in CD3+CD56+ lymphocytes. Before NC the ratio CD4/CD8 in group 1 was 2.25 +/- 0.5 and in group 2 it was 1.79 +/- 0.5 (P <0.05). CONCLUSIONS: Patients with advanced breast cancer showed increases in B and NK lymphocytes. Neoadjuvant chemotherapy (FEC) caused an increase in CD3+CD56+ and a decrease in B lymphocytes. Patients with an increased CD4/CD8 ratio have a better chance of responding to neoadjuvant chemotherapy.

Colposcopic scoring system for biopsy decisions in different patient groups.

Colposcopic scoring system have been used for distinguishing low-grade from high-grade cervical lesions. However, none of the previous studies have reported colposcopic scoring systems for biopsy decisions in different patient groups. The purpose of our study was to evaluate the safety of biopsy decisions using the colposcopic score elaborated by Stellato and Paavonen (IL) in 21 nonpregnant HIV infected patients (NP+) and 36 uninfected patients (NP-), 12 HIV infected pregnant patients (P+) and 20 uninfected pregnant patients (P-) in the diagnosis of cervical intraepithelial neoplasias (CIN) and HPV infection. The receiving operator curve was used for the establishment of a cut-off point in the scoring system graduation. The chi-square test was used for the statistical analysis. We obtained a safety cut-off value in the colposcopic scoring system for each patient group: 4.5 for NP+; 4.0 for NP- and 3.5 for P+ and P- patients. The sensitivity and specificity of the colposcopic score for the detection of high-grade lesions for each group were respectively: 87.5 and 92.3% for NP+ patients; 90.9 and 92% for NP- patients; 100 and 87.5% for P+ patients and 100 and 91.7% for P- patients. Our results suggest that the colposcopic scoring system is a practical tool for a colposcopy-guided punch biopsy decision and detection of high-grade cervical lesions in different patient groups. Further studies are needed to prove its clinical utility.

Hemangiosarcoma of the breast followed by term pregnancy.

AIMS AND BACKGROUND: Primary angiosarcoma of the breast is an unusual neoplasm which is generally associated with a dismal prognosis. Given the poor prognosis and the predominance in the third and fourth decades of life when fertility tends to decrease, reports of term pregnancies after treatment of this disease are rare. METHODS AND STUDY DESIGN: We report a case of angiosarcoma of the breast in a 17-year-old patient with a recurrent breast nodule treated by local surgery only. After three years of follow-up without evidence of disease recurrence she became pregnant. RESULTS: A girl weighing 2,430 g was delivered at 38 weeks and two days. The patient has been free of disease for five years now. CONCLUSIONS: Our experience of the present case shows the lack of full information about this tumor. Pregnancy does not seem to interfere negatively with the course of the disease.

Successful preservation of fertility subsequent to a complete pathologic response of a squamous cell carcinoma of the uterine cervix treated with primary systemic chemotherapy.

This is the first report about a successful pregnancy following treatment for advanced cervical cancer.

Reduced immunologic cell performance as a prognostic parameter for advanced cervical cancer.

The proliferative response of lymphocytes to mitogens is known to be decreased in cancer patients; this phenomenon is thought to play an important role in disease progression, but it has not been studied as a prognostic factor in cervical cancer patients receiving treatment. Fourteen patients with advanced cervical cancer submitted to chemotherapy with cis-platinum (100 mg/m2/cycle) and bleomycin (30 mg/cycle) over three cycles every 4 weeks were evaluated. Mean follow-up time was 30 months. The following laboratory tests carried out on peripheral blood lymphocytes collected before and at the end of chemotherapy were used as prognostic factors: proliferative response of lymphocytes to phytohemagglutinin (PHA) and stimulated with interleukin 12 (IL-12), capacity of gamma interferon production (IFN-gamma), and variations in memory T cell (CD45-RO) and naive T cell (CD45-RA) subsets. A clear correlation was obtained between response to treatment, survival rates, and PHA-induced proliferative response. A significant difference was observed in the number of CD45-RO lymphocyte at the pre-chemotherapy period and IFN-gamma production at the post-chemotherapy period in the group of good responders to treatment. The use of IL-12 produced a leveling in both groups for lymphocyte proliferation, i.e., a recovery from the deficiency presented by the lymphocyte of the poor responders group. The parameters of immunologic assays, especially proliferative response, appears to be correlated with prognosis and survival rates and therefore are good discriminating factors for the selection of groups of patients that will benefit from this type of treatment. IL-12 seems to play an important role in the regulation of the antitumor immune response and should be considered for therapeutic use.

Evaluation of staging, cytoreduction and second-look operation of 119 ovarian cancer patients.

OBJECTIVE: This study was conducted on patients with ovarian cancer in order to evaluate survival. DESIGN: A retrospective study of 119 cases of ovarian cancer from January 1977 to December 1992 with observation until 1993. LOCATION: Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, São Paulo University. PARTICIPANTS: Of the 119 cases, 70 (58.8%) presented epithelial carcinomas and 21 (17.6%) tumors of the sexual girdle/stroma. DATA SOURCE: The data were obtained from the medical records of the patients. MEASUREMENT: Statistical analysis of survival time was based on the nonparametric Mann-Whitney test with the level of significance set at P < 0.05. RESULTS: The patients with a negative second look had a mean survival of 79.4 +/- 48.5 months versus 24.2 +/- 15.1 months for patients with a positive second look (P < 0.02). CONCLUSIONS: It is concluded that patients with a negative second look present a better prognosis compared to those with residual disease.

Differential diagnosis of axillary masses.

Axillary masses are uncommon alterations when detected as an isolated finding. We evaluated 31 patients with isolated axillary masses. Patients with alterations of the breasts or the upper limbs or with Ipsilateral chest lesions were excluded from the study. Nine patients had occult breast cancer, 5 of them in the contralateral breast. Seven had metastatic lymph nodes of non-ductal origin, and 1 had carcinoma of apocrine cells with metastasis to the axilla. Four patients had benign lymphadenopathy which disappeared spontaneously, and 4 others had ruptured infundibular follicular cyst, nodular fibromatosis, inflammatory tuberculous and inflammatory rheumatoid lymphadenitis. Five had an ectopic breast (2 with a fibroadenoma and 3 with fibrocystic changes). One patient had an axillary lipoma. The mean age of patients with malignant pathology was 55.1 +/- 10.9 years, and the mean age of patients with a benign pathology was 43.1 +/- 14.7 (P < 0.01). Chest X-ray and bilateral mammography are useful when the cause of the mass cannot be determined by taking a detailed history of neoplastic or infectious antecedents, by careful physical examination of the skin of the arms, trunk and neck, or by palpation of the breasts and thyroid. Fine needle aspiration biopsy distinguishes between benign and malignant pathologies. In cases of indeterminate neoplasia, complete axillary dissection for diagnosis is indicated.

Selection of criteria for the treatment of ovarian cysts on the bases of ultrasound and cytology.

The major objective of the present study was to determine whether leakage of ovarian cyst cells occurs when the cysts are punctured inside a container with saline. Other subjectives were to determine the sensitivity and specificity of cytology in the differentiation between malignant and benign cysts by comparing cytology data with histology data, and also to determine whether ultrasound can provide consistent evidence for predicting whether the cyst is benign or malignant, thus permitting the selection of patients with benign cysts for puncture rather than surgical exeresis. A cytologic study was carried out on the contents of 62 ovarian cysts diagnosed by ultrasound and clinical examination, and excised from 51 patients submitted to exploratory laparotomy. The cyst was excised and immersed in a container with saline outside the surgical field. The cyst was punctured and its contents aspirated through the wall of the container. Five samples were obtained for cytology: (1) presurgical abdominal wash; (2) saline before cyst puncture; (3) fluid from the punctured cyst; (4) saline after cyst puncture, and (5) postoperative abdominal wash. The materials obtained were submitted to centrifugation and slides of the precipitate were prepared for cytology. A total of 248 slides were studied. Slides of cysts with good cellularity were stained with silver to study the nucleolar organizer regions. Analysis using Kappa statistics showed excellent agreement between the cytologic and histologic diagnoses (p < 0.001). The sensitivity of the cytologic study of the cyst was 75% and the specificity 100%, with a positive predictive value of 100%, a negative predictive value of 92%, and 93% accuracy. The present results led us to conclude that cell leakage into physiological saline occurred after puncture and that cytologic study of cysts valuable in the diagnosis of benign and malignant processes.

Mono and polichemotherapy in the treatment of metastatic and invasive gestational trophoblastic disease: analysis of 50 cases.

Fifty patients with metastatic or invasive gestational trophoblastic disease (GTD) were admitted at the "Hospital das Clínicas" of the Ribeirão Preto School of Medicine of the São Paulo University between January 1980 and December 1990. Of these 50 patients, 44 (88%) had GTD following abortion, 5 (10%) after term pregnancies and one (2%) after an ectopic pregnancy. Thirty five (70%) had invasive GTD and 15 (30%) metastatic GTD. The sites of metastases were: lung, 8 (53.3%), pelvis, 4 (26.6%), central nervous system, 2 (13.3%) and right auricle, 1 (6.6%). Human chorionic gonadotropin, pelvic arteriography and ultrasonography were used in the diagnosis of invasive GTD. 25 of the 41 patients with low-risk metastatic and invasive GTD were treated with monochemotherapy. There were 6 (24%) failures and the remaining 19 patients (76%) had complete remission of the disease after 2.89 mean cycles. Sixteen patients were treated with polichemotherapy, there were 2 (12.5%) failures and the remaining 14 had complete remission after a 2.3 mean cycles. No statistical differences between the two types of chemotherapy were observed. Four (8%) deaths were recorded.

[Evaluation of different technics of uterine evacuation as a risk factor for invasive and metastatic trophoblastic neoplasms]. / Avaliação de diferentes técnicas de esvaziamento uterino como fator de risco para neoplasia trofoblástica invasora e metastática.

A study was conducted to determine the effect of the form of uterine evacuation (curettage or vacuum aspiration) and of the use of oxytocin on the incidence of invasive/metastatic gestational trophoblastic neoplasia among patients with a diagnosis of molar abortion. The study was conducted on 42 patients with a histopathological diagnosis of benign complete hydatidiform mole and with a uterine height of more than 12cm. Twenty-five patients were submitted to uterine evacuation by curettage and 17 to uterine evacuation by vacuum aspiration. Twenty-seven of the same 42 patients received oxytocin to promote dilation of the cervix and/or partial mole expulsion, and 15 were not treated with this drug. Statistical analysis showed that the use of oxytocin before uterine evacuation was a factor contributing to a higher risk of development of invasive neoplasia, especially when associated with curettage of the uterus.

Aspectos epidemiologicos do cancer do colo uterino. / Epidemiological aspects of cancer of the uterine cervix

Os autores apresentam um estudo epidemiologico de 477 casos de cancer do colo uterino coletados no Hospital das Clinicas da Faculdade de Medicina de Ribeirao Preto, USP, onde sao avaliadas as seguintes variaveis: natureza pre ou invasiva do cancer, estado civil, estadiamento clinico, achados colposcopicos, idade do primeiro coito, paridade e frequencia de gestacao