Large cell neuroendocrine tumor of the cervix and human papillomavirus 16: a case report.

BACKGROUND: Large cell neuroendocrine cancer of the cervix is a rare entity. Most cervical cancers are high-risk human papillomavirus (HPV)-related neoplasms. CASE: A 31-year-old woman presented with pelvic pain and daily vaginal bleeding for 6 months. Uterine curettage revealed an undifferentiated malignancy. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic, common iliac, and periaortic lymphadenectomy and peritoneal cytology were performed. The pathological findings revealed a poorly differentiated large cell neuroendocrine carcinoma of the cervix with metastasis to 1 right obturator lymph node. Nonisotopic in situ hybridization stains were positive for high-risk HPV in the cervical tumor and in the lymph node metastasis in virtually every tumor cell indicative of viral integration into the host genome. Specific HPV typing by polymerase chain reaction was positive for HPV-16. CONCLUSIONS: Integration of high-risk HPV, in particular type 16, is associated with this uncommon variant of cervical carcinoma.

Preoperative serum CA-125 levels in treating endometrial cancer.

OBJECTIVE: To evaluate preoperative levels of CA-125 for the prediction of advanced stages of uterine cancer. STUDY DESIGN: Retrospective chart review of 141 women with endometrial cancer who were treated by a single gynecologic oncologist at a community teaching hospital in North Carolina between November 1994 and September 2002. RESULTS: Ninety-three of 106 patients (87.7%) with surgical stage I or II endometrial cancer had normal preoperative CA-125 levels. Ten of 11 (91%) women with stage IV endometrial cancer had elevated preoperative CA-125 levels. High CA-125 levels and positive lymph vascular space invasion correlated most strongly with advanced stage (p < 0.01). Similar trends in correlation of CA-125 levels were seen with the highest grade and the deepest myometrial invasion. The sensitivity and specificity of a CA-125 cutoff level of 35 U/mL were 63% and 88%, respectively, with a positive predictive value of 61% and negative predictive value of 89%. CONCLUSION: Measurement of preoperative CA-125 is a clinically useful test in endometrial cancer patients. CA-125 appears to be a significant independent predictor of the extrauterine spread of disease and is a better predictor of disease than depth of invasion or grade. This evidence complements a growing body of literature that supports the strong relationship between CA-125 level and stage of disease. A CA-125 level should be included as part of the preoperative workup for all patients with endometrial cancer.

Metastatic endocervical adenocarcinoma presenting as a virilizing ovarian mass during pregnancy.

BACKGROUND: We report a case of metastatic endocervical adenocarcinoma that presented as a virilizing ovarian mass in a young pregnant woman and simulated a primary ovarian endometrioid tumor. CASE: A 34-year-old woman underwent cesarean delivery and right salpingo-oophorectomy at 34 weeks' gestation for a 32-cm androgen-producing ovarian mass. The ovarian tumor, initially interpreted as a primary ovarian endometrioid carcinoma, was demonstrated to represent metastatic endocervical endometrioid adenocarcinoma based on detection of human papillomavirus 16 (HPV-16) deoxyribonucleic acid in the tumor by in situ hybridization. The hysterectomy specimen demonstrated an endocervical adenocarcinoma associated with adenocarcinoma in situ that also contained HPV-16. CONCLUSION: Human papillomavirus is considered an etiological agent in the development of endocervical adenocarcinomas, having been demonstrated in greater than 90% of tumors. In contrast, recent studies have concluded that HPV is unlikely to play an etiological role in ovarian neoplasia. The demonstration of HPV-16 in both the endocervical and ovarian carcinomas in this patient supports the interpretation that the ovarian tumor is a metastasis.

Fertility-sparing surgery for advanced juvenile granulosa cell tumor of the ovary.

BACKGROUND: Juvenile granulosa cell tumors (JGCT) of the ovary are rare. They usually present in children and adolescents. About 90% are diagnosed in early stage (FIGO I) with a favorable prognosis. More advanced stages (FIGO II-IV) usually have a poor clinical outcome. CASE: We report a case of long-term survival of a teenager with Stage III JGCT treated with aggressive debulking and thorough staging, but conservative surgery relative to the uterus, contralateral uninvolved ovary, and fallopian tube, plus combination chemotherapy. Her tumor recurred twice, 18 months and 17 years later, for which she had 2 additional surgeries and more chemotherapy. Our patient achieved 2 pregnancies and had 3 children. SUMMARY AND CONCLUSIONS: With fertility sparing surgery, patients may be able to achieve pregnancies and children.

Sarcoidosis mimicking recurrent endometrial cancer.

BACKGROUND: Sarcoidosis is a multisystem disease and can be confused with benign or malignant tumors. In patients with recurrent gynecologic cancer, liver and intrathoracic lesions should undergo a biopsy to rule in metastatic malignancy, as clinical findings and CAT scan results may represent other disease processes. CASE: A 67 year old woman had a total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and periaortic lymphadenectomy, and peritoneal cytology in 2001 for Stage I B grade 1 adenocarcinoma of the endometrium. She developed a vaginal recurrence in 2005. A CT scan of lungs, abdomen, and pelvis revealed extensive mediastinal adenopathy and multiple space occupying hepatic lesions worrisome for metastatic disease. A needle biopsy of the largest liver lesion revealed sarcoidosis. CONCLUSION: Sarcoid lesions may mimic metastatic disease in patients with malignancy, potentially leading to delayed and/or inappropriate therapy.

Gastric necrosis associated with acute gastric dilatation and small bowel obstruction.

BACKGROUND: While acute gastric dilation is a postoperative complication familiar to most surgeons, massive dilatation with necrosis and rupture is a very rare event. We performed a computer search in the MEDLINE database for the years 1966-2001 for articles published in any language using the key words gastric dilation, gastric necrosis, intestinal obstruction, and gynecologic surgery. Our search yielded no reports of massive gastric dilation and ischemic necrosis from a small bowel obstruction following gynecologic surgery. CASE: A 76-year-old woman developed massive gastric dilatation with ischemic necrosis associated with small bowel obstruction following gynecologic surgery for benign disease. CONCLUSION: Gynecologists should be aware of the entity. Early diagnosis and treatment are essential to minimize morbidity and mortality.