High dose para-aortic lymph node irradiation for gynecologic cancer: technique, toxicity, and results.

A technique for high dose (5600-6100 cGy) extended field irradiation to the para-aortic lymph nodes is described. Fourteen patients have been treated with this technique, of whom 10 have had histologic confirmation of para-aortic node metastases. With follow-up ranging from 11 to 78 months, 7 of 14 patients are alive and clinically cancer-free. Acute effects of extended field treatment on patient weight and circulating blood counts are analyzed, and late treatment morbidity assessed. The findings suggest that such treatment, executed with modern equipment and appropriate technique, is not significantly more hazardous than pelvic irradiation, and can result in a substantial probability of disease-free survival.

Adjuvant postoperative pelvic radiation for carcinoma of the uterine cervix: pattern of cancer recurrence in patients undergoing elective radiation following radical hysterectomy and pelvic lymphadenectomy.

Thirty-seven patients with invasive cervical cancer have been referred to the Department of Radiation Oncology at the University of Washington following radical hysterectomy and pelvic lymphadenectomy. Patients at high-risk for tumor recurrence were selected for adjuvant pelvic irradiation because of adverse risk factors identified on pathological study of the hysterectomy specimen. All patients were treated because of possible residual, microscopic carcinoma. Fourteen patients (38%) developed recurrent cancer, of whom 10 (27%) manifested initial failure within the irradiated volume. Possible explanations for this observation are discussed.

Combined radiotherapy and chemotherapy in the management of local-regionally advanced vulvar cancer.

PURPOSE: To determine, in a retrospective single institutional study, the role of concurrent radiotherapy and chemotherapy in the treatment of local-regionally advanced vulvar cancer. METHODS AND MATERIALS: From 1984 to 1991, 20 patients with locally extensive primary or recurrent carcinoma of the vulva were treated with initial combined radiotherapy and chemotherapy. Seven patients had Federation Internationale de Gynecologie et d'Obstretrique Stage III disease, 10 had Stage IV disease, and three were treated for recurrent disease. None of these patients were considered candidates for primary radical vulvectomy and groin node dissection. Median radiation doses to regions of microscopic disease and gross tumor were 40 Gy (range 30-54 Gy) and 54 Gy (34-70.4 Gy), respectively. All patients received 2 or 3 cycles of 5-Fluorouracil concurrently with radiotherapy. In addition, five patients received Cis-platinum, and one Mitomycin-C. Median at-risk follow-up interval was 37 months. RESULTS: Ten patients had complete resolution of tumor to initial chemoradiotherapy, and eight of these have remained free of tumor relapse. Eight other patients had partial responses, with tumor bulk reduced by > 50%, while the remaining two patients had local-regionally progressive disease. Six of the patients with partial responses had residual tumor successfully resected, although four subsequently recurred. For the entire group of 20 patients, the actuarial 3- and 5-year local control rates were 48% each, and the corresponding disease-specific survival rates were 59% and 49%. There was a suggestion that better local control was obtained in patients who received gross tumor radiation doses > or = 50 Gy. Skin reaction was the major acute toxicity and responded well to conservative management. Long-term sequalae were limited to skin and subcutaneous atrophy. CONCLUSION: These results indicate that initial combined radiotherapy and chemotherapy is effective in the management of advanced vulvar cancer.

Cryotherapy in the treatment of cervical intraepithelial neoplasia.

More than ten years of experience has now accumulated relating to the treatment of cervical intraepithelial neoplasia (CIN) by cryocautery. Cryotherapy has been established as an acceptable and effective therapeutic approach to CIN. Careful safeguards must be defined and respected to avoid the failure of diagnosing invasive carcinoma at the outset and to detect and manage persistent disease during follow-up. A treatment failure rate must be anticipated, but this failure rate does not appear excessive and is indeed comparable to that realized with other conservative forms of therapy. Presently, there appears to be no valid reason for proscribing or limiting the use of cryocautery in the treatment of CIN.

Stage I vulvar cancer: criteria for microinvasion.

Thirty-eight women with stage I epidermoid carcinoma of the vulva were studied retrospectively in an attempt to define the criteria for conservative therapy in early invasive vulvar cancer. Among the 38 women, 23 met the 6 criteria established for early invasive carcinoma of the vulva. In those 23 women, there were no nodal metastases. Depth of stromal invasion correlated strongly with the degree of tumor differentiation and the presence of carcinoma in situ (CIS). Stromal invasion less than 3 mm and presence of CIS were predictive of no involvement of the lymph nodes or endothelial-like space.

Malignant melanoma of the vulva: a case report of distal recurrence in a patient with a superficially invasive primary lesion.

Malignant melanoma of the vulva is a rare but highly lethal disease traditionally treated by radical surgery. Recently, data has been presented suggesting that less aggressive surgical management for superficially invasive lesions results in low levels of local recurrence and metastatic disease. We present a patient with a Clark level II superficial spreading melanoma of the vulva that developed distal recurrence after wide local excision.

Uterine smooth-muscle tumors of uncertain malignant potential.

OBJECTIVE: To determine whether tumors meeting the criteria of Hendrickson and Kempson for uterine smooth-muscle tumors of uncertain malignant potential have a natural history different from those of leiomyomas and leiomyosarcomas. METHODS: Tumors with five to ten mitoses per ten high-power fields and with mild or moderate cellular atypia were classified as tumors of uncertain malignant potential. Tumors with two to four mitoses per ten high-power fields and severe cellular atypia would also be classified as tumors of uncertain malignant potential, but we had no tumors that fell into this latter group. Forty-seven women with leiomyosarcoma or smooth-muscle tumors of uncertain malignant potential were identified. Paraffin-embedded blocks were recut, and hematoxylin and eosin-stained sections were studied for mitotic counts and cellular atypia. Statistical analysis used chi 2, Fisher exact test, Student t test, and Kaplan-Meier life table analysis. RESULTS: Fifteen tumors were classified as uncertain malignant potential and 32 as leiomyosarcomas. The patients with leiomyosarcoma were significantly older and more likely to present with extrauterine disease. Those with tumors of uncertain malignant potential had a 5-year disease-free survival of 66% and overall survival of 92%, compared to 28 and 40%, respectively, for leiomyosarcomas; these differences were statistically significant. Patients with tumors of uncertain malignant potential tended to have a protracted clinical course after development of recurrence, and several survived longer than 5 years with metastatic disease. CONCLUSIONS: Patients with five to ten mitoses per ten high-power fields and mild to moderate cellular atypia had a prognosis significantly better than that of patients with leiomyosarcomas. In this group, only 27% developed a recurrence, and after recurrence they tended to have a protracted course. Some of these tumors do have a very aggressive course, and the term "uncertain malignant potential" is appropriate.

Supraumbilical upper abdominal midline incision for pelvic surgery in the morbidly obese patient.

An upper abdominal midline incision was used for pelvic surgery in 16 morbidly obese patients (229-401 lb). When this approach is used, a Bookwalter retractor displaces the incision inferiorly and compresses the abdominal wall over the pelvis, and is then secured to the operating-room table. This approach provides adequate exposure of the pelvic organs and avoids an incision in the panniculus with its associated complications. No wound infections, postoperative dehiscences, or other serious postoperative morbidity occurred in these patients.

The morbidity and benefits of concurrent gracilis myocutaneous graft with pelvic exenteration.

This study was undertaken to evaluate the morbidity and potential benefits of concurrent gracilis myocutaneous graft with exenteration. All patients undergoing exenteration from 1962-1986 were reviewed, of whom 24 had concurrent grafts. The mean operative time, blood loss, and hospital stay were not different in patients with versus without grafts. The rate of fistula formation in the hospital was less in the graft group (P = .004) but was not different when compared with contemporary patients only. The total infection rate (wound and pelvic) was decreased in the graft group (P = .04) when graft infections were excluded. The major problem with the graft was significant necrosis of the flap(s) in nine of the 24 patients. There were no life-threatening complications attributed to concurrent placement of gracilis myocutaneous flaps. Experience with the technique is improving the cosmetic and functional outcome of the neovagina formed with the graft. Patients most likely to benefit from this procedure include those requiring immediate reconstruction or those with potentially poor healing due to high-dose pelvic radiation, including intraoperative radiation.

Glassy cell carcinoma of the cervix redefined.

Glassy cell carcinoma of the cervix has been classically regarded as a poorly differentiated adenosquamous carcinoma, infrequently diagnosed and associated with a poor outcome regardless of the modality of therapy. The histologic characteristics associated with this lesion are also frequently encountered among undifferentiated large-cell, nonkeratinizing cervical carcinomas. In a review of all undifferentiated large-cell carcinomas of the cervix encountered at the University Hospital in Seattle, Washington, over an eight-year period, 29 cases appeared to display the characteristic histologic criteria described as typical for glassy cell carcinoma. All cases were stage Ib lesions, and 28 were treated by radical hysterectomy. The mean age was ten years younger than that of the usual patient treated at this institution with stage I carcinoma. Fourteen of these patients (45%) have developed recurrent carcinoma, and in all but one, the interval to recurrence was less than eight months. Only two have survived after second-line salvage therapy. The current survival rate among the 29 women is 55%. These observations suggest that the poor prognosis ascribed to the classically defined glassy cell carcinoma also holds true for this extended group of large-cell, undifferentiated cervical cancers that display similar histologic features and pursue a similarly aggressive clinical course.

Osteomyelitis pubis after radical gynecologic operations.

The clinical and microbiologic features of five cases of osteomyelitis of the pubis after radical gynecologic and exenterative pelvic surgery are reported. Pain and tenderness over the pubic symphysis and difficulty with ambulation were common features. The interval between surgery and diagnosis ranged from eight to 17 weeks (average, 13.6 weeks). Erythrocyte sedimentation rate and alkaline phosphatase level were often abnormal, and x-rays, bone scan, and gallium scan were useful diagnostic tests. Osteomyelitis of the pubis contributed to an increased hospital stay of 5.6 weeks (mean) for patients undergoing radical vulvectomy and ten to 24 weeks for patients undergoing total pelvic exenteration. Intravenous antibiotic therapy followed by long-term oral administration may provide effective therapy, but the presence of necrotic bone requires surgical excision of necrotic and infected tissue.

Estrogen replacement therapy.

The use of estrogen replacement therapy in postmenopausal women is under close scrutiny. The indications and side effects of replacement therapy are reviewed, and recommendations regarding its use are made. Hot flashes, atrophy of the vaginal epithelium, and prevention of osteoporosis have been established as indications for estrogen replacement therapy. Prevention of cardiovascular disease, aging changes of skin, and the occurrence of mental illness have also been suggested as indications, but beneficial effects of estrogen replacement therapy for these problems have not been clearly established. Studies have shown that side effects of estrogen replacement therapy include endometrial cancer, hypertension, gallbladder disease, and angina pectoris. Breast cancer may also be a risk factor, but a consensus of opinion has not been established. Pulmonary embolism, cerebral vascular accident, or myocardial infarction has not been associated with estrogen replacement therapy. The use of progesterone with estrogen replacement therapy has been shown to reduce the occurrence rate of endometrial carcinoma, but it does not prevent all the actions of estrogen. Oral administration of estrogen is the preferred route despite misgivings about portal absorption and liver metabolism. Further studies must examine this question. Various agents have been shown to be effective in treating some climacteric symptoms. These include progesterone for hot flashes and calcium for the prevention of osteoporosis. Other agents may also be effective but have not been tested critically.

Patterns of recurrence of carcinoma following radical hysterectomy.

One hundred eighty-six radical abdominal hysterectomies are reviewed. Twenty-two instances of clinically recurrent carcinoma following operation were encountered over a 18-year period. In review of these cases it is apparent that patients with adenocarcinoma or adenocystic carcinoma have an increased likelihood of positive lymph node metastases or lymphatic-vascular invasion at the time of surgery. If this occurs, there is an increased probability of recurrent disease. Poor differentiation of the tumor, bulky disease, deep infiltration of tumor, involvement of capillary-like spaces, and lymph node metastases all appear to represent poor prognostic indices in patients operated upon. Patients with adenocarcinoma generally have a longer disease-free interval before recurrence than patients with squamous carcinoma. Postoperative radiation therapy following radical surgery appears to increase significantly the disease-free interval until recurrence and influences the site of recurrent disease but has no demonstrable effect on ultimate survival.

Adenocarcinoma of the uterine tube: potential for lymph node metastases.

A clinicopathologic study of 15 cases of primary adenocarcinoma of the uterine tube occurring over a 12-year period is presented. The mean age of the patients was 54.8 years. Predominant symptoms were abnormal bleeding, abnormal vaginal discharge, and pelvic pain. Abnormal vaginal cytology was noted in two instances (13%). A pelvis mass was detected in two thirds of patients. The neoplasm was bilateral in three instances (20%). Lymph nodes were involved in eight cases (53%), and metastatic spread to the para-aortic nodes was present in five (33%). The most common primary treatment was total abdominal hysterectomy and bilateral salpingo-oophorectomy. Various combinations of adjuvant radiation therapy and chemotherapy were also employed. Six patients (40%) are alive without evidence of recurrent cancer. It is concluded that lymphatic spread, especially to the para-aortic nodes, is a major pattern of disseminaton for adenocarcinoma of the uterine tube. The presence of tumor in capillary-like spaces bears a strong relationship to lymph node metastases, and the para-aortic nodes are a frequent site of involvement even when the disease is apparently limited to the tube.