Phase II study of cisplatin and vinorelbine as first-line chemotherapy in patients with carcinoma of the uterine cervix.

PURPOSE: To evaluate the activity and toxicity of the combination of cisplatin (80 mg/m2 day 1) and vinorelbine (25 mg/m2 days 1 and 8) in patients with carcinoma of the uterine cervix that has not been previously treated with chemotherapy. PATIENTS AND METHODS: Fifty patients with cervical cancer were enrolled onto this study (27 stage IB-III, 23 stage IVB-recurrent). A two-stage optimal Simon design was applied. Thirteen responders of 29 treated patients were required to proceed beyond the first stage, and 28 responders were needed overall. RESULTS: Hematologic toxicity was mild, with neutropenia being the most frequent side effect. Nonhematologic toxicity was frequent but never severe; one patient had grade 3 peripheral neurotoxicity. Objective responses were recorded for 32 patients (64%): 11 patients (22%) achieved a complete response (CR) and 21 patients (42%) achieved a partial response (PR). The response rate was 81.5% in patients with IB-III stage (25.9% CR rate) and 43.5% in patients with IVB-recurrent disease (17.4% CR rate). Responses were seen both in stage IVB patients (one CR and two PRs, for an overall rate of 37.5%) and in patients with recurrent disease (three CRs + four PRs, for an overall rate of 46.7%). CONCLUSION: The combination of cisplatin and vinorelbine is an active regimen in the treatment of patients with early-stage and advanced carcinoma of the uterine cervix. The hematologic and nonhematologic toxicity of this combination is mild.

Primary non Hodgkin's lymphoma of the vagina.

The genital tract as a primary site of malignant lymphoma in women is extremely rare. This report concerns a 64 year old patient with a primary vaginal non-Hodgkin lymphoma (large cell B lineage according to the REAL classification--centroblastic type according to the Kiel classification--"G" according Working Formulation) with an unusual clinical presentation--pelvic discomfort accompanied by frequent ureteral-like colic. Due to gynecological onset symptoms and the rarity of this extranodal primary site misinterpretation of a primary vaginal lymphoma as a benign inflammatory disease or endometriosis may occur. We emphasize the importance of their recognition and also the differential diagnosis of cervical lymphoma from other neoplastic and non-neoplastic lesions.

Non-Hodgkin lymphoma in a gynecologic service. A report of three cases.

Primary lymphoma arising in female genital tract organs is extremely rare. We report three cases of non-Hodgkin lymphoma which were encountered during a four-year period at our gynecologic department. One patient presented with an inguinal mass; another had a primary lymphoma of the vagina and the third had massive pelvic and para-aortic lymphomatous involvement. The gynecologists should be aware that, although rarely, lymphomas may arise in the genital tract, and that a massive involvement of inguinal, pelvic or para-aortic nodes may be related to a lymphoproliferative disease.

Prolonged survival of stage IV malignant mixed Müllerian tumor of the ovary after carboplatin, mesna, ifosfamide, and cis-platin chemotherapy: case report.

Malignant mixed müllerian tumors (MMMT) of the ovary are rare, aggressive and rapidly progressive tumors. According to the available literature, the presence of metastatic disease rarely permits long term survival. We report on a 64-year old patient with stage IV ovarian MMMT who achieved a surgically-documented complete response (CR) after 6 cycles of carboplatin, mesna, ifosfamide, cis-platin. Pelvic recurrence was diagnosed 14 months later; the patient received 6 cycles of the same regimen used as first-line chemotherapy which resulted in a second complete response lasting for 4 months. The patient died 37 months after initial diagnosis due to intestinal occlusion. In the current case Ca 125 was significantly increased at clinical presentation of disease but not at the time of recurrence.

Hypersensitivity reactions in ovarian cancer patients receiving paclitaxel.

OBJECTIVE: The aim of this study was to describe a rapid retreatment strategy in patients with paclitaxel hypersensitivity reactions. METHODS: A retrospective review of all patients receiving standard 3-hour infusion paclitaxel-based chemotherapy after proper premedication at the Department of Gynecologic Oncology, University of Bari between 1995 and 1998, was performed. All patients who developed hypersensitivity reactions to paclitaxel were identified and their treatment course and outcome were reviewed. A review of the literature on this subject is also presented. RESULTS: Eighty-six women were treated with 461 cycles of paclitaxel-based chemotherapy at our Unit. Twelve patients (14%) developed hypersensitivity reactions. All had received standard premedication consisting of corticosteroids and hystamine blockers. Hypersensitivity reactions consisted of isolated face flushes (3 patients), dyspnea and chest tightness (4 patients) or bronchospasm (5 patients). Eleven patients were rechallenged with the original paclitaxel solution starting at a slower rate after a second premedication with a double dosage of steroids. None of these patients had reactions in subsequent courses. Only one patient (the first of this series treated in February 1995), was retreated 5 days later under strict monitoring in intensive care unit. CONCLUSIONS: Retreatment with the original paclitaxel solution is safe in almost all patients with hypersensitivity reactions. The drug should be administered within the next 24 hours with a new premedication protocol.

Successful pregnancy in a patient with Churg-Strauss syndrome.

Vasculitis syndromes rarely occur in association with pregnancy and usually have a poor prognosis. We report the case of a 32-year-old woman, affected by Churg-Strauss syndrome in complete remission at the time of conception, who completed a successful pregnancy. The patient did well except for a recurrence of allergic rhinitis and asthma which apparently responded to an increase in steroid dosage. Clinical implications of vasculitis and pregnancy are discussed.

Pure lipoma of the uterus in association with endometrial carcinoma.

Pure lipoma of the uterus is a very rare entity, with few cases described in the English literature. We report the case of a 71-year-old woman, with pure lipoma of the uterus and coexistent endometrial carcinoma and discuss the possible relationship between these pathologic entities.

Surgical decompression and radiation therapy in epidural metastasis from cervical cancer.

Spinal cord compression by epidural metastasis is considered an exceptional complication in patients with cervical carcinoma. We report three patients treated for a cervical carcinoma who developed epidural metastasis with spinal cord compression at 9, 25 and 48 months after primary treatment of the uterine malignancy. All patients had poorly-differentiated adenocarcinomas with lymphovascular space invasion, and two had lymph node metastasis. All patients underwent emergency decompressive laminectomy followed by radiotherapy and a partial recovery of the neurological function was achieved. In two patients the spinal cord was the only site of recurrent disease, whereas the other had lung and brain metastasis at the time of epidural involvement diagnosis. All three patients, however, died of disseminated disease. Surgical decompression followed by radiation therapy may result in a complete preservation of the neurologic functions in patients with spinal cord compression secondary to metastatic carcinoma of the uterine cervix. Considering the propensity for disseminated disease, long term survival might be achieved only with the use of effective chemotherapy.

Surgical treatment of recurrent ovarian cancer: report of 21 cases and a review of the literature.

AIM: To evaluate the role of secondary cytoreductive surgery in patients with recurrent ovarian cancer. PATIENTS AND METHODS: A retrospective chart review was conducted on 21 patients submitted to secondary cytoreductive surgery for apparently isolated and resectable recurrence of ovarian cancer, after a disease-free interval of at least 12 months. RESULTS: Fifteen patients (71%) had complete surgical debulking with no macroscopic tumor at the completion of the surgical procedure. Eight patients (38%) required an intestinal resection but no colostomy was performed. Eleven complications were recorded in nine patients, but no operative death occurred. The median survival time for all patients after diagnosis of recurrent disease was 29 months (range 6-96 months). Survival time after diagnosis of recurrence was not significantly related either to known prognostic factors of ovarian cancer or to the length of the clinical remission time. The absence of residual disease after salvage surgery was the only factory associated with prolonged survival. CONCLUSION: Secondary cytoreductive surgery is a safe procedure which should be offered to recurrent ovarian cancer patients with apparently isolated and resectable disease, and without ascitis.

Surgical resection of a cerebral metastasis from cervical cancer: case report and review of the literature.

AIMS AND BACKGROUND: Central nervous system metastasis from cervical carcinoma is uncommon. CASE REPORT: We report the case of a 51-year-old woman who developed a solitary cerebral metastasis 29 months after radical hysterectomy with pelvic lymphadenectomy for a stage IB, grade III cervical cancer. The patient suddenly complained of headache, confusion and dizziness; she was submitted to emergency surgical resection of a 2 x 3 cm metastasis in the right frontal lobe. The postoperative course was uneventful and she completely recovered from her neurological deficit. Following surgery the patient underwent careful restaging. Massive bilateral involvement of the pelvic wall was diagnosed, and the patient received three courses of cisplatin-based chemotherapy. She developed liver and lung metastases and died 10 months later of progressive disseminated disease, without, however, any sign of recurrent or persistent cerebral involvement. CONCLUSION: Neurosurgical resection should be considered in cervical cancer patients with solitary brain metastasis in the absence of systemic disease.

Lymphocyte subpopulations in patients with cervical cancer.

The evaluation of the immunological aspects in cervical cancer has been a point of major interest in the past few years. Data found in literature are, however, often confusing. In order to identify changes in cell mediated immunoresponse in these malignancies, we have studied the lymphocyte subpopulations from peripheral blood samples in women with FIGO intraepithelial + IB stages vs a control group. The analysis of our results show evidence of an increase in the number of natural killer cells even in intraepithelial tumors. The activation of the immunological system from the very early stage is probably in response to viral antigens in the neoplastic cells and/or soluble factors produced by the tumor.

Abnormal cervical PAP smear leading to the diagnosis of gastrointestinal cancer without cervico-vaginal metastases.

We report the case of an unsuspected G.I. cancer in a patient with no clinical signs other than ascites and positive PAP-smear on admission. Histologically, neither endometrium nor cervix were involved. To date, only 2 cases of primary gastrointestinal (gastric) cancers with no metastases to the cervix, suspected by PAP-smear, have been reported in medical literature. A few more have been reported with cervical metastases. The suspicion of intraabdominal adenocarcinoma was based on the evidence of signet ring cells found in the smear with negative cervical biopsies and negative fractional curettage. A postmortem examination confirmed the absence of genital involvement. Our aim is to remind the clinician that an abnormal PAP-smear, due to non gynecological malignancies, can, on rare occasions, be observed. In order to obtain a positive cervico-vaginal PAP-smear by a non gynecologic intraabdominal exfoliating cancer, both previous literature and our case suggest peritoneal effusion to be of major importance.

Endometrial stromal sarcoma: a clinicopathologic study.

BACKGROUND: This study is a clinicopathologic evaluation of five patients with endometrial stromal sarcoma. PATIENTS AND METHODS: Over a period of 9 years 5 cases of ESS were observed in our Unit. The patients were retrospectively staged according to the FIGO staging system for endometrial cancer. The neoplasm was divided into two groups based on mitotic activity. Patients underwent endouterine curettage, surgery therapy and, except one of them, chemotherapy. RESULTS: Two patients had low-grade ESS stage Ib and Ic. The other three had high-grade ESS, and were in stage IIIa. Treatment was surgery for all patients, and adjuvant chemotherapy for 4 out of 5. Both patients in stage I are alive, clinically free from the disease, 25 and 36 months after diagnosis. In stage III all patients died 14, 25 and 36 months after diagnosis. CONCLUSION: ESS is a rare uterine neoplasm. Histologic grade is the most important prognostic factor.

Primary malignant melanoma arising in an ovarian dermoid cyst: proposed use of radioimmunoscintigraphy with 99mTc-F(ab')2 antimelanoma antibody for staging and follow-up. Case report.

A case of primary amelanotic ovarian malignant melanoma arising in a dermoid cyst is presented. Grossly, inside the cyst, pigmented solid lesions were not detected. Histologically, an area with undeniable malignant microscopic features was revealed and its melanomatous identity was confirmed by positive S-100 protein and melanoma antigen immunoreactivity. Recently, after 21 months from surgery this patient has also undergone radioimmunoscintigraphy (RIS) with 99mTc labelled antimelanomatous antibodies which revealed a possible secondary paracolic localization. Regardless of this evidence, although the patient has always refused chemotherapy and second look surgery for removal of the suspicious area, she is alive 1 year after surgery and now doing well. The authors also report the usefulness of employing the RIS technique in evaluating the metastatic spread in this type of malignancy.

Prognostic factors and selective use of vaginal hysterectomy in early stage endometrial carcinoma.

INTRODUCTION: Endometrial cancer represents the fourth most frequent malignancy in women of any age, tending to become the most common gynaecological tumor in developed Countries. A retrospective analysis has been conducted on the prognostic factors of endometrial neoplasm during 15-years experience (1977-1991). MATERIAL AND METHODS: 321 patients affected by stage I and II endometrial carcinoma have been treated surgically first hand. Surgical-pathological staging and prognostic factors were reviewed and related to follow-up and 5-year survival rate. RESULTS: The age-peak of patients was 50-70 years; prevalent histologic type was adenocarcinoma (95.6%); 269 patients were in stage I and 52 in stage II. In stage I disease overall 5-year survival rate resulted to be 81.4%, while in stage II it fell to 59.6%. DISCUSSION: Myometrial involvement by adenocarcinomatous cells is probably the most important prognostic factor, considering its reliability and non-contradictory evaluation. Our data confirm there is no difference in impact on 5-year survival between abdominal and vaginal routes in clinical stage I and occult stage II endometrial carcinoma.

[Peritoneal tuberculosis with elevated CA-125 serum levels]. / Tubercolosi peritoneale con elevati livelli serici di CA-125.

Peritoneal tuberculosis is uncommon today. Its symptoms are insidious and non-specific, simulating symptoms of peritonitis carcinomatosa. We report the case of a 35-year-old woman with ascites and elevated serum CA-125 levels, in which explorative laparotomy with the previsional diagnosis of ovarian carcinoma, revealed peritoneal tuberculosis. After treatment with bacteriocidal chemotherapeutic agents, the serum CA-125 returned to normal, and the patient has been well for 12 months postoperatively. Serum CA-125 levels are elevated in the case of peritoneal tuberculosis, and the possibility of this rare pathology should always be considered in patients with a previsional diagnosis of peritonitis carcinomatosa.

[Familial neoplastic syndromes of the ovary. A family study]. / Sindromi neoplastiche familiari dell'ovaio. Studio di una famiglia.

The authors describe a case of Lynch II type familial ovarian cancer syndrome. The family was first observed following the almost contemporary manifestation of ovarian cancer in two sisters. A subsequent analysis of family history among first and second degree relatives showed the presence of ovarian cancer in two maternal aunts, carcinoma of the colon in the father and breast cancer in a sister of the patients. Surgical treatment was selected for ovarian cancer associate with polychemotherapy in both cases. The patients' only living sister underwent preventive ovariectomy at the end of her reproductive programme. The latter is still undergoing follow-up due to the risk of developing neoplasia starting from the peritoneum. The diagnosis of ovarian cancer should result in a careful analysis of the pedigree of the patient suffering from the disease in order to highlight cancer at an early stage in other members of the same family.

[A case of Leydig cell virilizing tumor of the ovary]. / Un caso di tumore virilizzante a cellule di Leydig dell'ovaio.

A case of Leydig cell virilizing tumor of the ovary in a 68 year old woman, with clinical signs of virilization, clitoromegaly and androgenic alopecia is described. An RMN of encephalon and an abdominal ultrasound were normal. Following total abdominal hysterectomy and bilateral salpingo-oophorectomy, the patient had regression of hirsutism, and plasma testosterone dropped to normal level.

[Transvaginal color-Doppler sonography for monitoring the response to neoadjuvant chemotherapy in patients with locally advanced cervical cancer]. / Eco color-Doppler transvaginale nel monitoraggio della risposta alla chemioterapia neoadiuvante in pazienti con cervicocarcinoma localmente avanzato.

Changes in blood flow characteristics, observed with transvaginal color-Doppler ultrasonography have recently been reported in patients with advanced cervical cancer. In order to evaluate the reliability of TVCDUS in monitoring the response to neoadjuvant chemotherapy in patients with locally advanced cervical cancer, a prospective study was undertaken on the blood flow characteristics of the cervical vessels. Pulsatility Index (PI) and Resistance Index (RI) of the uterine and cervical arteries of 12 patients with histologically proven advanced cervical cancer, scheduled for neoadjuvant chemotherapy were evaluated at diagnosis, during every cycle of chemotherapy and before surgery. A significantly lower value of mean PI and RI between cervical and uterine arteries was observed in patients with cervical cancer (PI = 1.671 +/- 0.18 vs 2.159 +/- 0.24)-(RI = 0.43 +/- 0.17 vs 0.72 +/- 0.22). Mean RI and mean PI of the descending branches of the uterine arteries were significantly lower in patients with cervical cancer, compared to healthy control women. No difference in blood flow parameters could be detected between stage I vs stage II-III, and between left and right cervical artery in patients with cervical cancer. Both RI and PI values appeared strictly related to the tumor response to chemotherapy. In fact in 8 patients in which treatment resulted in tumor regression, evaluated by pelvic examination and MR imaging, a significant (p < 0.01) increase of resistance indices was observed (PI = 1.671 +/- 0.18 vs 2.158 +/- 0.22)-(RI = 0.43 +/- 0.17 vs 0.79 +/- 0.16). On the other side 4 patients not responding to chemotherapy, had stable values of both PI and RI. Transvaginal color-Doppler ultrasonography might be useful in monitoring the response to neoadjuvant chemotherapy in patients with locally advanced cervical carcinoma.

[Sarcoma of the endometrial stroma]. / Il sarcoma dello stroma endometriale.

BACKGROUND: To evaluate the most important risk factors and the efficacy of endometrial stromal sarcoma therapy. METHODS: During a period of 9 years, 5 cases of ESS have been observed at the IInd Obstetrical and Gynecological Institute of the University of Bari. The patients were staged according to the FIGO classification of endometrial carcinoma and studied from an epidemiological, histopatological and clinical point of view. All patients firstly received uterine courettage and then total simple laparohysterectomy. In 4 cases bilateral salpingo-oophorectomy and then polychemotherapy. Only in 1 case total hysterectomy and monolateral salpingo-oophorectomy were performed. RESULTS: Two patients were affected by low grade ESS malignancy respectively at Ib and Ic stage and received only surgery. High grade ESS malignancy was diagnosed in 3 patients at stage IIIa and they received surgery followed by chemotherapy. These 3 patients survived for 14, 25 and 30 months. The other two are still alive, with no evidence of the disease at 25 and 36 months. CONCLUSION: ESS is a rare neoplasm; the low grade malignancy may survive from 80-100%, while the high ones can have a fatal prognosis with exitus in 12-30 months.