Stage III uterine carcinosarcoma: 2009 International Federation of Gynecology and Obstetrics Staging System and Prognostic Determinants.

OBJECTIVES: (1) To determine the significance of positive peritoneal cytology and pelvic versus para-aortic lymph node involvement in uterine carcinosarcoma. (2) To evaluate the impact of isolated retroperitoneal lymph node involvement (IIIC-N) versus retroperitoneal lymph node involvement plus other evidence of extrauterine disease spread (IIIC-N+) on survival in patients with stage IIIC uterine carcinosarcoma. METHODS: Data were extracted from the Surveillance, Epidemiology, and End Results database between 1988 and 2005. Statistical analysis used χ, Kaplan-Meier method, and Cox proportional hazards model. RESULTS: A total of 690 women were identified. When comparing overall survival between patients with disease spread to uterine serosa and/or adnexa and those with positive peritoneal cytology, there was no significant difference (25.4% vs 15.5%, P = 0.2). However, although the 5-year overall survival was comparable between patients with positive pelvic lymph nodes and those with positive para-aortic lymph nodes (22.1% vs 25.4%, P = 1.0), it was significantly worse in stage IIIC-N(+) compared to stage IIIC-N patients (15.0% vs 33.4%, P < 0.001). Only patient's age (P < 0.001), race (P = 0.03), stage (P < 0.03), and lymphadenectomy (P < 0.001) were independent predictors of survival after adjusting for other contributing factors. In addition, the results of unadjusted analysis concerning the survival difference between different stage groups were confirmed on multivariate analysis. CONCLUSIONS: Positive peritoneal cytology is associated with poor prognosis in uterine carcinosarcoma, comparable to current International Federation of Gynecology and Obstetrics stage IIIA classification of disease. Although there does not seem to be a significant survival difference between patients with positive pelvic versus those with para-aortic lymph nodes, the prognosis seems to be much worse in patients with stage IIIC uterine carcinosarcoma with other evidence of extrauterine disease spread, suggesting the need for more aggressive therapy.

Stage IIA1 versus stage IIA2 cervical cancer: does the new staging criteria predict survival?

OBJECTIVE: (1) To determine the correlation of 2008 International Federation of Gynecology and Obstetrics staging system with survival in patients with stage IIA cervical cancer, (2) to elucidate the treatment patterns in stage IIA1 and stage IIA2 cervical cancer, and (3) to investigate whether radical hysterectomy or radiation influenced overall survival. METHODS: Data were extracted from the Surveillance, Epidemiology and End Results database between 1988 and 2005. Statistical analysis used χ test, Kaplan-Meier method, Cox regression, and logistic regression. RESULTS: Of the 560 women, 271 (48.4%) had stage IIA1, and 289 (51.6%) had stage IIA2 cervical cancer. Stage IIA2 patients were younger than stage IIA1 patients (mean age, 49 years vs 54 years; P = 0.01). Stage IIA1, compared with stage IIA2, differed significantly regarding the administration of primary radiation (47.2% vs 64.7%, P < 0.001) and adjuvant radiation (60.5% vs 77.5%, P = 0.006). The following variables were significantly associated with the performance of radical hysterectomy: patient age, 65 years or younger, tumor size, ≤ 2 cm or lesser, high tumor grade, and nonsquamous tumor histology. The incidence of adjuvant radiation after radical hysterectomy was high (48% [tumor size, ≤ 2 cm] to 86% [tumor size, >6 cm]). The 5-year overall survival was not significantly different between stages IIA1 and IIA2 (65.8% vs 59.5%, P = 0.2). Only patient age (P = 0.01), tumor size (P = 0.02), and lymph node status (P = 0.002) were independent predictors of survival. When controlled for other contributing factors, there was no significant difference in survival between patients treated by radical hysterectomy and primary radiation. CONCLUSIONS: The 2008 International Federation of Gynecology and Obstetrics staging criteria is not an independent predictor of survival in stage IIA cervical cancer. Given the equivalent efficacy of radical hysterectomy and radiation, attention should be paid to the high risk of adjuvant radiation in these patients.

The impact of a multidisciplinary conference in the management of cervical cytological and histological abnormalities: a university hospital experience.

OBJECTIVE: This study evaluates the impact of a cytology-colposcopy correlation conference (CCCC) on the management of preinvasive cervical lesions in a university hospital. METHODS: This is a retrospective analysis of 130 consecutive cases from the colposcopy clinic at our University Health Center that were presented in the CCCC during a period of 1 year (November 2006 to October 2007). Variables examined to assess the usefulness of CCCC included the actual number of times there was a recorded change in the diagnosis or management recommendation secondary to presentation in the conference. The algorithms from the 2001 American Society of Colposcopy and Cervical Pathology consensus guidelines for the management of cytologic and histologic abnormalities were used to identify the patients in whom the conference recommendations were a deviation from the standard society recommendations. RESULTS: The diagnosis was changed on review of the original cytology or biopsy 24 times (13%), downgraded 13 times (7%), and upgraded 11 times (6%). The conference recommendations were a modification of the standard 2001 American Society of Colposcopy and Cervical Pathology guidelines 38 times (21%) in 34 patients. The most common triage change was the recommendation for observation of unexplained high-grade cytology with negative or lower-grade biopsy (73%), followed by observation of high-grade lesion on biopsy (27%). This recommendation, while an option in the 2006 guidelines, was not given as a choice in the 2001 guidelines. CONCLUSIONS: The CCCC at our institution provided significant input into the management of patients with preinvasive cervical lesions, anticipating some of the changes made in the 2006 guidelines.

Current concepts in the evaluation of multiple myeloma with MR imaging and FDG PET/CT.

Multiple myeloma is a heterogeneous group of plasma cell neoplasms that primarily involve bone marrow but also may occur in the soft tissue. Although the disease varies in its manifestations and its course, it is eventually fatal in all cases. Over the past 2 decades, significant advances have been made in our understanding of the genetics and pathogenesis of multiple myeloma and in its treatment. The use of magnetic resonance (MR) imaging and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) with computed tomography (CT) has improved sensitivity for the detection of this disease. PET aids in the identification of active multiple myeloma on the basis of FDG uptake, and MR imaging helps identify multiple myeloma from its infiltration of normal fat within the bone marrow, which occurs in characteristic patterns that correlate with the disease stage. The increased sensitivity of these advanced cross-sectional imaging techniques has led to further refinement of the classic Durie and Salmon staging system. In addition, these imaging techniques allow a more reliable assessment of the disease response to treatment with current regimens, which may include autologous stem cell transplantation as well as various medications. In lesions that respond to chemotherapeutic agents, the replacement of previously infiltrated marrow by fat is seen at MR imaging and decreased FDG uptake is seen at FDG PET; however, a lengthy and intensive regimen may be necessary before the MR imaging appearance of marrow normalizes. Lytic lesions seen at CT almost always persist even after successful treatment. To provide an accurate assessment, radiologists must be familiar not only with the appearances of multiple myeloma and its mimics but also with common treatment-related findings.

Comparison of whole-body PET/CT, dedicated high-resolution head and neck PET/CT, and contrast-enhanced CT in preoperative staging of clinically M0 squamous cell carcinoma of the head and neck.

UNLABELLED: The purpose of this study was to compare optimized whole-body (WB) and dedicated high-resolution contrast-enhanced PET/CT protocols and contrast enhanced CT in the preoperative staging of primary squamous cell carcinoma of the head and neck. METHODS: A total of 44 patients with clinically M0 squamous cell carcinoma of the head and neck underwent primary tumor resection and neck dissection within 6 wk of diagnostic imaging. Imaging consisted of a standard WB PET/CT protocol without intravenous contrast enhancement, followed by a high-resolution dedicated head and neck (HN) PET/CT protocol, which included diagnostic-quality contrast-enhanced CT (CECT). Imaging results were compared with histopathology. A 5-point scale was used to designate primary tumor localization and the presence of lymph node metastasis on a per-patient and per-level basis. For cervical nodes, receiver-operating-characteristic curves were generated to determine the differences in performance between the WB and HN PET/CT protocols and CECT. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated for primary tumor and cervical nodes. RESULTS: No statistical difference was observed between WB and HN PET/CT protocols, both of which significantly outperformed CECT, in the evaluation of the primary tumor. The performance of the HN PET/CT protocol was superior to that of the WB PET/CT in the detection of cervical node metastases, achieving statistical significance on a per-level basis and approaching significance on a per-patient basis, with the greatest advantage in the detection of small positive lymph nodes (<15 mm). No significant difference was observed between the WB PET/CT protocol and CECT in nodal staging, either on a per-patient or on a per-level basis. CONCLUSION: The primary advantage of the dedicated HN PET/CT protocol over the WB protocol or CECT in the staging of head and neck cancer is in the detection of small lymph node metastases.

Management of chemical dependence in pregnancy.

Although the percentage of pregnant patients who use illicit drugs is relatively low, the effects can be devastating on both mother and fetus-loss of custody, growth restriction, placental abruption, and death. The practicing obstetrician may be unfamiliar with the various presentations of chemical dependency in pregnancy, including intoxication and withdrawal, and difficulty in making the diagnosis. The obstetrician is in the unique situation of being responsible for the safety of both mother and fetus, which may involve engaging the unwilling patient in treatment.

Detectable prostate specific antigen between 60 and 120 days following radical prostatectomy for prostate cancer: natural history and prognostic significance.

PURPOSE: Following radical retropubic prostatectomy for prostate cancer, if the serum prostate specific antigen fails to become undetectable, occult micrometastatic disease is suspected. We assessed the natural history of disease progression, and predictors of recurrence and survival in this group of patients. MATERIALS AND METHODS: We identified 303 men treated with radical retropubic prostatectomy for prostate cancer between 1990 and 1999, who had a detectable prostate specific antigen between 60 and 120 days postoperatively. Systemic recurrence-free and cancer specific survival were estimated using the Kaplan-Meier method, and analyzed using Cox proportional hazards models. RESULTS: Clinical and pathological features were more adverse among men whose postoperative prostate specific antigen was detectable. These men had poorer systemic recurrence-free survival and cancer specific survival compared to men with an undetectable postoperative prostate specific antigen, and even men whose prostate specific antigen subsequently became detectable. These differences persisted after multivariate adjustment for preoperative prostate specific antigen, specimen Gleason score, seminal vesicle and margin status. With a median followup of 8.5 years, 50 systemic recurrences and 26 deaths from cancer were observed. Gleason score and the prostate specific antigen doubling time were multivariate predictors of systemic recurrence, while Gleason score, margin status and seminal vesicle invasion were predictors of death from cancer. CONCLUSIONS: A detectable prostate specific antigen immediately following radical retropubic prostatectomy confers an increased risk of progression and death, but only in a subset of patients, who may be identified on the basis of pathological features and prostate specific antigen doubling time. In future such patients may be suitable for trials of systemic therapy.

Reversal of hypermetabolic brown adipose tissue in F-18 FDG PET imaging.

OBJECTIVES: With the increasing application of F-18-fluorodeoxyglucose (FDG) positron emission imaging, there has been an evolving appreciation for the range of normal variants and the realization that false-positives can lead to serious consequences. RESULTS: One of the most common causes of a false-positive study is the uptake of FDG in areas of hypermetabolic brown adipose tissue (HBAT). Areas of involvement are often spatially closely related to important lymph node groups in the neck, axilla, and upper mediastinum, making critical differentiation difficult, even with PET-CT. CONCLUSIONS: FDG uptake in HBAT has been noted to occur more frequently in cold months and benzodiazepines have been proposed for its prevention. The use of these drugs is, in our experience, of limited value and may complicate patient care in both inpatient and outpatient populations. In this report, we describe considerable success by completely reversing HBAT in 9 of 10 sequential patients with simple core warming maneuvers, which obviate the use of benzodiazepines.