Ovarian carcinoma diagnosis.

BACKGROUND: Ovarian carcinoma often is called the "silent killer" because the disease usually is not detected until an advanced stage. The authors' goal was to evaluate preoperative symptoms and factors that may contribute to delayed diagnosis for women with ovarian carcinoma. METHODS: A two-page survey was distributed to 1500 women who subscribe to CONVERSATIONS!, a newsletter about ovarian carcinoma. Because the survey could be copied and given to other patients, 1725 surveys were returned from women in 46 states and 4 Canadian provinces. RESULTS: The median age of the surveyed women was 52 years, and 70% had Stage III or IV disease (International Federation of Gynecology and Obstetrics). When asked about symptoms before the diagnosis of ovarian carcinoma, 95% reported symptoms, which were categorized as abdominal (77%), gastrointestinal (70%), pain (58%), constitutional (50%), urinary (34%), and pelvic (26%). Only 11% of women with Stage I/II and 3% with Stage III/IV reported no symptoms before their diagnosis. Women who ignored their symptoms were significantly more likely to be diagnosed with advanced disease compared with those who did not (P = 0.002). The time required for a health care provider to make the diagnosis was reported as less than 3 months by 55%, but greater than 6 months by 26% and greater than 1 year by 11%. Factors significantly associated with delay in diagnosis were omission of a pelvic exam at first visit; having a multitude of symptoms; being diagnosed initially with no problem, depression, stress, irritable bowel, or gastritis; not initially receiving an ultrasound, computed tomography, or CA 125 test; and younger age. The type of health care provider seen initially, insurance, and specific symptoms did not correlate with delayed diagnosis. CONCLUSIONS: This large national survey confirms that the majority of women with ovarian carcinoma are symptomatic and frequently have delays in diagnosis.

Impact of surgical staging in women with locally advanced cervical cancer.

OBJECTIVE: The aim of this study was to evaluate the impact of surgical staging in the treatment and outcome of women with locally advanced cervical cancer. METHODS: Ninety-eight women with locally advanced cervical cancer treated between 1993 and 1997 were retrospectively reviewed. Survival probabilities were calculated by the Kaplan-Meier product limit method and compared with the log-rank test. RESULTS: Of the 98 women treated over the 5-year period, 86 were surgically staged: 61 by a retroperitoneal approach, 18 by laparoscopy, and 7 by laparotomy. Median blood loss was 120 cc and median length of hospitalization was 3 days. Preoperative CT scans (n = 55), when compared with surgical findings, missed macroscopic nodal disease in 20% and microscopic disease in 15% and overcalled disease in 10% of cases. Lymph node metastases were found in 45/86 patients (52%): 12 microscopic and 33 macroscopic. The highest level of nodes found to be involved was pelvic in 23, common iliac nodes in 3, para-aortic nodes in 14, and scalene nodes in 5 cases. Of the 86 patients, 49 received pelvic radiation, 27 received extended field radiation, and 10 were identified for palliative treatment only (5 scalene node metastasis, 5 extensive intraperitoneal disease). For node-negative patients, 5-year survival was 74%; for microscopic nodal involvement it was 58%; and for macroscopic involvement it was 39% (P = 0.007). Five-year survival for women with para-aortic node involvement was 52%. Number of nodes involved was a significant prognostic variable (P = 0.008). Patients who received chemotherapy had a 5-year survival of 68% compared to 35% for those who did not (P = 0.06). Factors which did not affect survival included age, histology, type of surgery, stage, and type of radiation (pelvic vs extended). CONCLUSION: Surgical staging of women with locally advanced cervical cancer can be performed with acceptable morbidity and it provided more accurate information than CT scans and resulted in a modification of the standard pelvic radiation field for 43% of our patients. The information obtained from surgical staging allows better individualization of therapy, which may improve overall clinical outcome.

"Curbside" consultations in gynecologic oncology: a closer look at a common practice.

OBJECTIVE: The aim of this article is to evaluate the nature and frequency of informal "curbside" consultations in a gynecologic oncology practice. METHODS: A log of all curbside consultations requested from a gynecologic oncologist in a tertiary multispecialty group practice was kept for 2 years (July 1996 to June 1998). New referrals or calls concerning mutual patients were excluded. RESULTS: Three hundred thirty-three requests for advice were received from 87 different physicians. Most (81%) of the calls were from 51 obstetrician/gynecologists (Ob/Gyns); 13% of the calls were from family practitioners or general internists. The four most common topics discussed were lower genital tract dysplasia (18%), endometrial hyperplasia (17%), adnexal masses (11%), and endometrial cancer (10%). Overall, 29% of questions pertained to the management of an invasive gynecologic malignancy. Twenty-four percent of the questions were answered in less than 5 min, 43% in 5-10 min, 29% in 11-20 min, and 4% in over 20 min. The issues discussed were considered simple in 26%, of moderate complexity in 49%, very complex in 22%, and ultracomplex in 3%. One hundred nine questions (33%) were of sufficient complexity to warrant referral to a specialist, which occurred in 52 cases (48%); physicians employed by a staff-model health maintenance organization were less likely to request a formal consultation (14%, chi(2) = 0.001). CONCLUSIONS: Curbside consultations are a frequent occurrence in the practice of a gynecologic oncologist, with most questions posed by general Ob/Gyns. Approximately one-third of the questions were of minimal complexity and involved topics covered in standard textbooks or residency training programs. In contrast, approximately one-third were of sufficient complexity that a casual discussion between colleagues may not yield optimal medical care.

Port-site recurrence after laparoscopic surgery for endometrial carcinoma.

BACKGROUND: Women with endometrial carcinoma are being treated with laparoscopic surgery, but the risk of port-site recurrences remains undefined. CASE: A 58-year-old woman underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic lymphadenectomy for endometrial cancer. Final surgical stage was IA, with grade 2 histology. Twenty-one months later, she developed a 5-cm recurrent tumor mass at a lateral laparoscopic port site. The mass was resected, and a restaging laparotomy performed, without evidence of other metastases. Radiation therapy was administered to the involved anterior abdominal wall. Two and one half years later, there is no evidence of recurrence. CONCLUSION: An isolated laparoscopic port-site recurrence might be attributable to the initial laparoscopic management of an otherwise good-prognosis endometrial carcinoma.

Oncogene expression: long-term compared with short-term survival in patients with advanced epithelial ovarian cancer.

OBJECTIVE: To determine if oncogene overexpression in patients with advanced epithelial ovarian cancer correlates with survival. METHODS: Twenty-two women with stage III ovarian cancer, observed for a median of 66 (range 48-204) months were compared with 30 with a median survival of 18 (range 2-28) months. Using immunocytochemistry, tumors were immunostained for overexpression of p53, c-erb-B-2, and epidermal growth factor receptor and were evaluated quantitatively for expression of estrogen receptor, progesterone receptor, and Ki-67 antigen, a marker of cellular proliferation. RESULTS: The median age of long-term survivors was 52 (range 30-76) years compared with 55 (range 36-80) years for short-term survivors. Optimal cytoreduction was achieved in 11 of the 22 long-term survivors compared with seven of the 30 short-term survivors, a significant difference (P=.05). The average level of Ki-67 expression was 43% in long-term survivors and 64% in short-term survivors (P=.007). Overexpression of p53 was seen in 54% of long-term survivors and 80% of short-term survivors (P=.05). A combination of Ki-67 level of 50% or greater plus p53 overexpression was seen in 22% of long-term survivors compared with 68% of short-term survivors (P=.005). Epidermal growth factor receptor, c-erb-B-2, estrogen receptor, and progesterone receptor statuses did not differ significantly between the two groups. CONCLUSION: Markers that did not correlate with survival included the hormone receptors, estrogen receptor and progesterone receptor, and the oncogenes, c-erb-B-2 and epidermal growth factor receptor. Long-term survivors with advanced ovarian cancer were more likely to have had an optimal cytoreduction and lower levels of Ki-67 antigen expression and were less likely to overexpress p53 than were short-term survivors.

Adenocarcinoma of the uterine cervix metastatic to lymph nodes.

OBJECTIVE: We set out to evaluate the prognostic factors in cervical adenocarcinoma metastatic to lymph nodes. STUDY DESIGN: We performed a retrospective review of 40 patients with cervical adenocarcinoma and lymph node metastasis from 1976 to 1996. RESULTS: Thirty-four patients had adenocarcinoma, and six had adenosquamous carcinoma. Median survival was 50 months. The median survival for patients with stage I disease was 69 months. Stage at diagnosis, treatment with radical hysterectomy, and receiving adjuvant therapy were associated with prolonged survival. A trend toward improved survival was noted with the use of concurrent radiation and chemotherapy as an adjuvant therapy. CONCLUSIONS: Adenocarcinoma metastatic to the lymph nodes does not have a uniformly poor prognosis, especially with early-stage disease. Improved survival was observed with the use of adjuvant therapy, specifically the use of combined chemotherapy and radiation after radical hysterectomy. The optimal therapy in this setting is yet to be determined.

Uterine papillary serous carcinoma: evaluation of long-term survival in surgically staged patients.

OBJECTIVE: Earlier studies have demonstrated that the uterine papillary serous carcinoma (UPSC) variant of endometrial carcinoma has a high recurrence rate, even when disease is apparently confined to the uterus. The current study evaluated survival in patients with surgically staged UPSC. METHODS: Patients with UPSC were identified from surgical pathology files and charts were retrospectively reviewed. Only patients who had undergone a TAH-BSO, lymph node dissection, and peritoneal cytology were included. RESULTS: The FIGO stages of the 36 patients were 12 Stage I (4 IA, 4 IB, 4 IC), 2 Stage IIB, 13 Stage III (5 IIIA, 8 IIIC), and 9 Stage IV. Of the 14 Stage I/II patients, 6 did not receive adjuvant therapy, 5 received whole pelvic radiation (WPXRT), and 3 received whole abdominal radiation therapy (WART); after a median follow-up interval of 50 months only 2 (14%) of these Stage I/II patients have developed a recurrence. Both of the recurrences were in Stage IC patients who received radiation; 1 recurred in the radiation field. Of the 5 Stage IIIA patients, 3 patients declined therapy and 2 were treated with WART; 3 patients, including the 2 who received radiation therapy, are alive without disease. Of the 8 Stage IIIC patients, 2 declined postoperative therapy, 2 received WART, and 4 received WPXRT with an extended field to include paraaortic nodes. Four of the 6 Stage IIIC patients treated with curative intent are without evidence of disease and 1 died of unrelated causes after a median follow-up interval of 48 months. Both of the Stage IIIC patients who declined treatment recurred. Of the 9 patients with Stage IV disease, 8 have died of disease. CONCLUSION: Women with UPSC have a good prognosis when surgical staging confirms that disease is confined to the uterus (Stage I/II). Surgical findings can also be used to tailor adjuvant radiation treatments. Further study is required to define the optimal treatment for women with metastatic UPSC.

Comparison of 1997 Medicare relative value units for gender-specific procedures: is Adam still worth more than Eve?

BACKGROUND: On January 1, 1992, Congress implemented a Medicare payment system based on relative value units (RVUs). The total RVU (which is made up of work, practice, and malpractice RVUs) is multiplied by a dollar conversion factor to set the reimbursement for all procedures covered by Medicare. In a previous study, we found that significant gender bias exists in Medicare reimbursement for female-specific services. Recently, HCFA approved increases (beginning January 1997) in the work RVU for many gynecologic procedures. This study was undertaken to compare work and total RVUs for gender-specific procedures effective January 1, 1997. METHODS: Using the May 1996 Federal Register, we compared work and total RVUs for 24 pairs of gender-specific procedures. The groups were matched so that the amount of work and level of difficulty would be similar, if not identical. We validated our selection of procedures for comparison by also evaluating the average time required to perform these procedures. RESULTS: Comparison of work RVUs for the 24 paired procedures revealed that in 19 cases (80%), male-specific procedures had a higher RVU; in 3 cases (12%), female-specific procedures were higher; and in 2 cases, there was no difference. On average, work RVUs were 49% higher for urologic procedures than for gynecologic procedures. Comparison of total RVUs revealed that in 20 cases (83%), urologic procedures had a higher total RVU and in 3 cases (12%), gynecologic procedures were higher. On average, male-specific surgeries are reimbursed at an amount which is 37% higher than that for female-specific surgeries. CONCLUSION: Recent increases in work RVUs for many gynecologic procedures have resulted in improved reimbursement. However, even with these improvements, significant gender bias still exists in the Medicare reimbursement of female-specific procedures. This gender bias is further magnified as more private insurance carriers use the system to set reimbursement.

Is Adam worth more than Eve? The financial impact of gender bias in the federal reimbursement of gynecological procedures.

PURPOSE: On January 1, 1992, Congress implemented a Medicare payment system based on relative value units (RVU). The RVU multiplied by a dollar conversion factor sets the reimbursement for all procedures covered by Medicare and many other private insurers. This study was undertaken to evaluate discrepancies in federal reimbursement for gender-specific procedures. METHODS: Using the December 1995 Federal Register and the regional Medicare conversion factor ($40.08/RVU), we compared the work RVU and total reimbursement of 24 groups of gender-specific surgical procedures. The groups were matched as carefully as possible so that the amount of work and level of difficulty would be similar, if not identical. Some examples of comparisons are as follows: biopsy of male vs female genitals, hysterectomy vs prostatectomy, staging for ovarian vs testicular cancer, and exenteration for cervical vs prostate cancer. RESULTS: In the 24 matched procedures, the male-specific procedures were reimbursed at a higher amount in 19 (79%) cases. The female-specific procedures were reimbursed at a higher amount in 3 (12%) cases (P = 0.004). There was no difference in reimbursement for two of the comparisons. Overall, we found that male-specific procedures are reimbursed at an amount which is 44% higher than female-specific procedures. Comparison of work RVU revealed that male-specific procedures were assigned higher values in 19 cases and, overall, male gender-related surgeries had work RVU that were 50% higher than female gender-related surgeries. CONCLUSION: There is significant gender bias against the Medicare reimbursement of female-specific services. This results in a lower net reimbursement for gynecologic procedures. In addition, since many private sector insurance carriers now use the resource-based relative value scale system, this gender bias is further potentiated.

Clear cell carcinoma of the ovary: a distinct histologic type with poor prognosis and resistance to platinum-based chemotherapy in stage III disease.

Between 1982 and 1992, 24 women with Stage III clear cell ovarian cancer were identified from the tumor registry. Thirty-four women with Stage III papillary serous tumors treated between 1987 and 1989 were used as a comparison. All patients underwent cytoreductive surgery followed by conventional platinum-based chemotherapy. In the women with clear cell histology, nine (37.5%) had endometriosis in the surgical specimen compared with one (3%) in the papillary serous group (P = 0.002). Ten women (42%) with clear cell histology experienced a thromboembolic event during the course of treatment, compared to six (18%) in the papillary serous group (P = 0.05). In the group with clear cell histology, overall, 70% of women had progressive disease. Fifty-two percent experienced clinical progression while receiving platinum-based chemotherapy. In addition, four patients were found to have progressive disease at second-look laparotomy. Only two patients had a pathologic complete response. In the group with papillary serous histology, 29% overall had progressive disease while on chemotherapy (P = 0.005). The median survival for the women with clear cell histology was 12 months compared to 22 months for those with papillary serous (P = 0.02). For women with clear cell histology, univariate analysis was used to evaluate prognostic factors. Age less than 50 was a poor prognostic factor (P = 0.045). The presence of endometriosis, thromboembolic event, or optimal cytoreduction were not prognostic factors (P = 0.67, P = 0.34, P = 0.39). Patients with advanced clear cell ovarian cancer have a poor response to conventional platinum-based chemotherapy and overall prognosis is poor.

Overexpression and relationships of HER-2/neu, epidermal growth factor receptor, p53, Ki-67, and tumor necrosis factor alpha in epithelial ovarian cancer.

OBJECTIVE: To determine the frequency and possible relationships of overexpression of oncogenes, cytokines, and cellular proliferation proteins in ovarian cancer. METHODS: Sixty-four epithelial ovarian cancer specimens were obtained from the GOG tumor bank. Using immunocytochemistry, tumors were stained for overexpression of HER-2/neu, epidermal growth factor receptor (EGFR), p53, tumor necrosis factor alpha (TNF alpha), and Ki-67 (a marker of cellular proliferation). RESULTS: Twenty-one tumors were Stage I/II and 43 were Stage III/IV. HER-2/neu was overexpressed in 7 cases (11%), EGFR in 12 cases (19%), and p53 in 32 cases (50%). Ki-67 was expressed in all but one case, and high indices (expression in over 50% of cells) were seen in 18 cases (28%). TNF alpha was expressed in all but one case. Comparison between Stage I/II and Stage III/IV cases revealed no difference in the expression of these oncoproteins. Comparison by histologic grade also revealed no difference in the expression of the oncoproteins, except for EGFR, which was overexpressed only in Grade 3 tumors (p = 0.01). Comparison between tumors that did or did not overexpress p53 revealed insignificant differences in the expression of HER-2/neu, EGFR and TNF alpha. In addition there were no differences with respect to stage, grade, or histology when tumors where analyzed with respect to p53 overexpression. There was a trend towards an association between p53 overexpression and high levels of Ki-67 (p = 0.10). Comparison of tumors with high Ki-67 indices to those with lower indices also revealed no association with the expression of HER-2/neu, or EGFR, and there were no differences in stage or grade distribution. CONCLUSION: Ki-67 and p53 were frequently overexpressed in this representative sample of ovarian cancers from the GOG tumor bank; however, their expression was not associated with stage, grade, histology, or overexpression of other oncoproteins. Lack of a recognizable pattern of oncogene overexpression emphasizes the underlying biologic complexity of ovarian cancer.

The expression of epidermal growth factor receptor, HER-2/Neu, p53, and Ki-67 antigen in uterine malignant mixed mesodermal tumors and adenosarcoma.

Uterine malignant mixed mesodermal tumors (MMMT) are highly malignant tumors containing both malignant glands and stroma, while adenosarcomas (AS) are less aggressive tumors composed of malignant stroma and benign glands. Immunohistochemistry was used to grade overexpression of p53 protein, HER-2/neu protein, epidermal growth factor receptor (EGFR), and Ki-67 antigen in both the glands and stroma of tissue from 20 women with MMMT and 6 women with AS. EGFR was overexpressed in 2 AS and 9 MMMT, and was more commonly found in the sarcomatous component than the carcinomatous component in MMMT (P = 0.03). p53 was not found in any AS samples and was strongly present in 6 MMMT samples with a random distribution between the malignant components. HER-2/neu protein was not overexpressed in any AS or primary MMMT. Ki-67 antigen, a marker of cell proliferation, was found at higher levels in MMMT than AS samples (P = 0.03) and high Ki-67 antigen expression correlated with a decreased survival in patients with MMMT (P = 0.004). Independent characterization of oncogene proteins in the malignant components of these heterogeneous tumors may provide insight into the histogenesis and behavior of these malignancies.

Malignant mixed müllerian tumors of the ovary: experience with surgical cytoreduction and combination chemotherapy.

BACKGROUND: The role of surgical cytoreduction and combination chemotherapy for malignant mixed müllerian tumors (MMMT) of the ovary was evaluated. METHODS: A retrospective review of 27 women with ovarian MMMT treated from 1980 to 1990 was performed. RESULTS: The International Federation of Gynecology and Obstetrics stages for the 27 women were 1 Stage I, 3 Stage II, 17 Stage III, and 6 Stage IV. Only 10 of the 23 patients with Stage III or IV disease were cytoreduced optimally. With respect to postoperative therapy, 3 women received no treatment, 6 were treated with whole abdomen radiotherapy, 1 received melphalan, and 17 received chemotherapy incorporating a platinum agent (3), doxorubicin (4), or both (10). The significant prognostic factors were stage (P < 0.001) and, for women with Stage III or IV disease, the feasibility of cytoreductive surgery (P = 0.03). The four patients in Stages I or II remained disease free after an interval of at least 5 years. The median and 5-year survival rates for patients with Stages III or IV disease was 18 months and 8%, respectively. Patients in Stage III or IV for whom optimal cytoreduction was not possible had a 2-year survival of 14%, whereas optimal cytoreduction was associated with a 52% 2-year survival. Median survival for the 14 women with Stage III or IV ovarian MMMT treated with combination chemotherapy was 25 months and nine women achieved progression free intervals of greater than 18 months. CONCLUSIONS: Aggressive surgical cytoreduction followed by combination chemotherapy may result in improved progression free intervals for women with advanced ovarian MMMT. However, a major improvement in prognosis for this rare malignancy has not yet been achieved.

Uterine papillary serous carcinoma: patterns of metastatic spread.

Uterine papillary serous carcinoma (UPSC) is a distinct histologic type of endometrial cancer which is associated with a high relapse rate and poor prognosis. Between 1983 and 1993, 50 patients with UPSC of the endometrium were surgically staged. Thirty-three patients had pure UPSC and 17 had UPSC admixed with other histologies. Extrauterine disease was found in 36 women (72%). Lymph node metastases were present in 36% of women without myometrial invasion, 50% with inner one-half invasion, and 40% with outer one-half invasion. Similarly, the presence of intraperitoneal disease or positive washings did not correlate with increasing myometrial invasion. Grade and histology (mixed vs pure) were also not predictive of extrauterine disease. Patients with lymphatic/vascular space invasion (LVSI) were more likely to have extrauterine disease (85%); however, even without LVSI the incidence of extrauterine disease was 58% (P = 0.05). Unlike endometrioid adenocarcinomas, grade and depth of myometrial invasion were not significant predictors for extrauterine disease. This study reinforces the need for complete surgical staging in all patients with UPSC regardless of depth of invasion.

Surgical stage IV endometrial carcinoma: a study of 47 cases.

Between 1976 and 1991, 47 patients with surgical Stage IV endometrial carcinoma were treated. Patients were identified from the tumor registry and charts were retrospectively reviewed. Surgical curves using the Kaplan-Meier product-limit method and Cox regression analysis were used to identify independent prognostic factors. Overall, median survival was only 12 months. Using univariate analysis there was no statistically significant difference in survival between age (P = 0.41), histology (P = 0.54), grade (P = 0.91), disease site (P = 0.32), or clinical stage (P = 0.87). In patients whose disease was surgically cytoreduced, the median survival was 18 months compared to 8 months in those who did not undergo surgery (P = 0.0001). Evaluation of other treatment modalities by univariate analysis revealed improved survival in those patients who received cyclophosphamide, doxorubicin, and cisplatin (P = 0.0007), decreased survival in those who received radiation therapy compared to surgery (P = 0.023), and no statistically significant difference in survival with progestins. By multivariate analysis successful cytoreduction was the only statistically significant prognostic variable (P = 0.04). This 15-year retrospective review confirms that prognosis for women with Stage IV endometrial cancer is extremely poor. However, if hysterectomy with cytoreduction is feasible, surgery should be performed because survival may be improved.

Large loop excision of the transformation zone in patients with exocervical squamous intraepithelial lesions.

This study was undertaken to determine factors influencing the success of loop excisions. One hundred twenty-seven women with exocervical intraepithelial lesions underwent large loop excision of the transformation zone (LLETZ); 102 returned for evaluation at 3 months. The pretreatment biopsies were low grade squamous intraepithelial lesions (LGSIL) in 37 cases and high grade squamous intraepithelial lesions (HGSIL) in 90. For the 37 women with LGSIL, the LLETZ specimen revealed no residual SIL in 13 (35%), LGSIL in 16 (43%), and HGSIL in 8 (22%). For the 90 women with HGSIL on pretreatment biopsy, 17 (19%) had no SIL, 10 (11%) had LGSIL, and 63 (70%) had HGSIL. Of the 102 women who returned for reevaluation, colposcopy was satisfactory in 89. There were 9 failures and all of these occurred in women with HGSIL in the LLETZ specimen. In the 17 women with involved margins there were 6 failures (35%); in the 85 women with uninvolved margins there were 3 failures (4%) (p = 0.005). The success of loop excisions is influenced by the grade of intraepithelial neoplasia and status of the margins of the LLETZ specimen.

Primary leiomyosarcoma of the fallopian tube.

Primary leiomyosarcoma of the fallopian tube is an extremely uncommon neoplasm. We report a 39-year-old premenopausal woman with leiomyosarcoma confined to the right fallopian tube, who is alive without evidence of disease 2 years after surgical resection followed by adjuvant doxorubicin and cisplatin chemotherapy. An accompanying literature review indicates that the clinical signs and symptoms of fallopian tube sarcomas are usually nonspecific and include lower abdominal pain and pelvic pressure. The age at diagnosis varies from 21 to 70 years, with a median of 47 years. Prognosis is poor, however, several longterm survivors have been reported. The primary treatment remains surgical excision, although adjunctive chemotherapy or radiation may be of some benefit.

Uterine leiomyosarcoma and endometrial stromal sarcoma: lymph node metastases and sites of recurrence.

This study was undertaken to examine the incidence and conditions under which lymph node metastases are present and patterns of recurrence in women with uterine leiomyosarcoma (LMS) and endometrial stromal sarcoma (ESS), excluding malignant mixed mesodermal tumors. From 1981 through 1991, 21 women with LMS and 10 women with ESS were treated. Retroperitoneal lymph node dissections were performed in 15 women with LMS and 7 women with ESS. In the women with LMS, 4/15 (26.7%) had lymph node metastases; in each there was disseminated intra-abdominal disease. In the 7 women with ESS, there were no lymph node metastases present. Ten women (47%) with LMS developed recurrences, and 3 (14%) had persistent disease. In the 10 women with ESS, 3 (30%) had recurrences, and 1 (10%) had persistent disease. In total, recurrences involved the lung in 84% of cases. Of the 13 women with recurrences, 7 had undergone lymph node sampling, and all were negative; 4 additional women had no evidence of adenopathy on abdominal-pelvic CT scan. Lymph node metastases were found only with extrauterine disease, and in all of these cases there was rapid progression of the sarcoma. Women without extrauterine disease did not have lymph node metastases detected; however, there was still a high rate (40%) of distant failure. Knowledge of lymph node status had minimal impact on the clinical management of women with uterine LMS and ESS.

Small chest-tube drainage followed by bleomycin sclerosis for malignant pleural effusions.

OBJECTIVE: To review our experience with bleomycin sclerotherapy as treatment of pleural effusions due to gynecologic malignancies. METHODS: Twenty-one women with histologically documented malignant effusions (16 ovarian carcinoma, three uterine sarcoma, and two cervical cancer) were treated with small flexible chest-tube drainage followed by intrapleural bleomycin sclerotherapy (60 units). RESULTS: After placement of the chest tube, suction was required for a median of 5 days (range 3-12) before output was low enough (less than 100 mL/24 hours) to instill bleomycin. Among 24 treated effusions, there was a 71% overall response rate, including ten complete responses (42%) and seven partial responses (29%); seven effusions (29%) did not respond to therapy. Six of the seven patients whose effusions did not respond to bleomycin died of disease within 2 months of attempted sclerotherapy. Fever was the most common side effect, occurring in 13 of 21 patients (62%) following instillation of bleomycin. Pain during sclerosis was reported by only two patients. CONCLUSIONS: Bleomycin sclerotherapy after small flexible chest-tube drainage of malignant pleural effusions is an effective technique, with minimal adverse reactions, for controlling effusions that develop in women with gynecologic malignancies.