Ovulatory failure, fertility preservation and reproductive strategies in the setting of gynecologic and non-gynecologic malignancies.

The advances in assisted reproductive technology over time have paralleled the insights gained into the natural history of different gynecologic malignancies. Subgroups of young patients with early stage ovarian cancer, endometrial carcinoma and cervical carcinoma may be considered to be at relatively low risk of recurrence and may be treated conservatively with the aim to preserve fertility when this is of prime concern. Unilateral adnexectomy with preservation of the contralateral ovary and uterus may be appropriate for some patients with epithelial ovarian cancers, and certainly should be the procedure of choice for those young women with borderline tumors and early stage sex cord-stromal and malignant germ cell tumors. Administration of high-dose progestins may obviate the need for immediate hysterectomy in a young patient with a well-differentiated endometrial carcinoma desirous of childbearing. The performance of vaginal radical trachelectomy in conjunction with laparoscopic pelvic lymphadenectomies has emerged as a real breakthrough for a highly select group of young women with early invasive tumors of the cervix. In this review, we also discuss reproductive strategies for women who experience chemotherapy-induced ovulatory failure and also address the potential for ovarian cortex cryopreservation and transplantation, and uterine transplantation, all of which are looming on the horizon.

Primary lung choriocarcinoma masquerading as a metastatic gestational neoplasm.

Primary lung choriocarcinoma has rarely been reported. In females, previous pregnancies and other sources of trophoblastic tissue such as a nongestational gonadal choriocarcinoma must be excluded before the diagnosis can be made. Here we present a young female patient initially diagnosed as having a metastatic gestational neoplasm who was unresponsive to standard single and multiagent chemotherapy. A total abdominal hysterectomy and bilateral salpingo-oopherectomy failed to reveal the source of production of beta HCG. At the time of her thoracotomy and lobectomy, performed for a lung nodule, she was found to have a primary lung choriocarcinoma. The patient received no further chemotherapy and has remained disease free for more than 3 years. This is the first recorded case of a lung choriocarcinoma that has been successfully treated where the patient has remained free of disease for more than 1 year.

Chemotherapy of advanced ovarian epithelial carcinoma with melphalan and levamisole: a pilot study of the Gynecologic Oncology Group.

Twenty-three patients with Stage III, Stage IV, or recurrent epithelial ovarian cancer were treated with a combination of melphalan and levamisole to determine a tolerable dosage schedule, possible adverse effects, and a general estimate of response rate and duration. In seven patients with measurable disease there were four complete responses (57%) with a median duration of 75 weeks. Two of the complete responders have had negative second-look laparotomies while the other two patients have had subsequent progression. Of 16 patients with nonmeasurable disease two have had negative second-look laparotomies and two remain progression free. Thus 8 of 23 patients (35%) had complete responses or remain progression free whereas 4 of 23 patients (17%) have had negative second-look laparotomies. No serious toxicity was encountered. Immunologic monitoring did not indicate significant immunologic reconstitution in these immunosuppressed patients.

Surgical approach to multifocal carcinoma in situ of the vulva.

Thirty-nine patients with multifocal carcinoma in situ of the vulva were managed with en bloc removal of the involved skin and a split-thickness skin graft to the surgical defect. The characteristic presentations of this clinical entity are reported and options for the therapy are discussed. Thirty-nine percent of the patients developed a recurrence, but none of the recurrences was within the donated skin graft. No reports of dyspareunia or seriously altered sexual function were noted. The details of the surgical approach ae outlined and modifications of the original procedure are described.

The role of postoperative irradiation in the management of stage I adenocarcinoma of the endometrium.

A comparison of treatment protocols for endometrial carcinoma is presented. Valid conclusions regarding optimum approach are virtually precluded because of variability of such factors as clinical staging, incidence of vaginal metastases, patient selection, and histologic grade. While hysterectomy is the established definitive treatement, the superiority of adjuvant irradiation can be demonstrated only by randomized prospective studies.

Immunologic responses in patients with lepromatous leprosy.

Immunologic responses were measured in 46 patients with lepromatous leprosy. These patients were not distinguishable from controls on the basis of responses to soluble intradermal antigens, sensitization to contactants, peripheral blood T- and B-cell percentages, in vitro lymphocyte responses to a mitogen, or the prevalence of autoantibodies. Generalized immunologic abnormalities in patients with lepromatous leprosy are neither predisposing causes nor necessary accompaniments of lepromatous leprosy, but are probably remote sequellae of the illness. By implication, the generalized immunologic abnormalities reported in other diseases are likely to be remote sequellae of the particular illness.

Immunologic responses in patients with lepromatous leprosy

Immunologic responses were measured in 46 patients with lepromatous leprosy. These patients were not distinguishable from controls on the basis of responses to soluble intradermal antigens, sensitization to contactants, peripheral blood T- and B-cell percentages, in vitro lymphocyte responses to a mitogen, or the prevalence of autoantibodies. Generalized immunologic abnormalities in patients with lepromatous leprosy are neither predisposing causes nor necessary accompaniments of lepromatous leprosy, but are probably remote sequellae of the illness. By implication, the generalized immunologic abnormalities reported in other diseases are likely to be remote sequellae of the particular illness.

Endodermal sinus tumor: a report of two sustained remissions treated postoperatively with a combination of actinomycin D, 5-fluorouracil, and cyclophosphamide.

The literature reflects a poor prognosis for women with endodermal sinus tumor. Two women with this neoplasm, 1 having stage IA and the other stage IIB disease were treated for 1 year postoperatively with a combination of actinomycin-D, 5-fluorouracil, and cyclophosphamide. Each had therapy discontinued after a negative second laparotomy and 15 and 21 months later are without recurrence. It is suggested that this drug regimen is a benficial adjunct to surgery in the treatment of endodermal sinus tumor.

Pelvic exenteration.

Pelvic exenteration offers the only possibility for cure in patients who have pelvic recurrence after receiving optimum amounts of irradiation. With improved radiotherapy techniques, the number of patients with isolated central failure is steadily diminishing, but there remains a significant number of patients with recurrent cancer of the cervix after radiation therapy for whom the procedure offers the only chance for life. Each patient must be assessed individually, with the risks of the procedure weighed against the possible benefits. Technical advances continue to reduce the operative mortality and ameliorate the postoperative morbidity associated with pelvic exenteration.